# THE ILLINOIS MEDICAL ASSISTANCE TREATMENT PROGRAM LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Green Dragonfly
- **Organization subpart:** No

## Provider details

- **NPI number:** 1407008998
- **Authorized official:** DR. RICHARD L KELLER (MEDICAL DIRECTOR)
- **Authorized official phone:** (847) 360-1019

## Contact information

- **Practice address:** 1738 WASHINGTON ST, WAUKEGAN, IL 60085-5137
- **Practice address phone:** (847) 360-1019
- **Practice address fax:** (847) 360-6277
- **Mailing address:** 1738 WASHINGTON ST, WAUKEGAN, IL 60085-5137
- **Mailing address phone:** (847) 360-1019
- **Mailing address fax:** (847) 360-6277

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261Q00000X | Clinic/Center | A27740001A | IL | Yes |

## Other

- **Enumeration date:** 10/16/2008
- **Last updated:** 10/16/2008