Provider Demographics
NPI:1902269095
Name:AUNT MATHA'S YOUTH SERVICE CENTER
Entity Type:Organization
Organization Name:AUNT MATHA'S YOUTH SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PCP - FAMILY PRACTICE MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-275-1540
Mailing Address - Street 1:898 BROMPTON CIR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1485
Mailing Address - Country:US
Mailing Address - Phone:847-420-9664
Mailing Address - Fax:
Practice Address - Street 1:19990 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1021
Practice Address - Country:US
Practice Address - Phone:708-747-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1275992323261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1275992323OtherNATIONAL PLAN & PROVIDER ENUMERATION