Organization
AUNT MATHA'S YOUTH SERVICE CENTER
Active
Organization
AUNT MATHA'S YOUTH SERVICE CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. CLARENCE PARKS MD (PCP - FAMILY PRACTICE MEDICINE)
(815) 275-1540
Entity
Organization
Contact information
Practice address
19990 GOVERNORS HWY, OLYMPIA FIELDS, IL 60461-1021
(708) 747-7100
Mailing address
898 BROMPTON CIR, BOLINGBROOK, IL 60440-1485
(847) 420-9664
Taxonomy
Speciality
Code
Description
License number
State
261QH0100X
Health Service Clinic/Center
Primary
1275992323
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1275992323
NATIONAL PLAN & PROVIDER ENUMERATION
IL
Enumeration date
04/05/2016
Last updated
04/05/2016
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