Organization
THE ILLINOIS MEDICAL ASSISTANCE TREATMENT PROGRAM LLC
Active
Other names
Green Dragonfly
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RICHARD L KELLER (MEDICAL DIRECTOR)
(847) 360-1019
Entity
Organization
Contact information
Practice address
1738 WASHINGTON ST, WAUKEGAN, IL 60085-5137
(847) 360-1019
(847) 360-6277
Mailing address
1738 WASHINGTON ST, WAUKEGAN, IL 60085-5137
(847) 360-1019
(847) 360-6277
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
A27740001A
IL
Other
Enumeration date
10/16/2008
Last updated
10/16/2008
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