1174809503 NPI number — AUNT MARTHA'S YOUTH SERVICE CENTER INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174809503 NPI number — AUNT MARTHA'S YOUTH SERVICE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUNT MARTHA'S YOUTH SERVICE CENTER INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174809503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19990 GOVERNORS HIGHWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA FIELDS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60461-1021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-747-7100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 COPPERFIELD AVENUE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
JOLIET
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60432-2056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-747-7100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
NORDLOH
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
708-747-7100

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  077 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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