Aunt Marthas Youth Service Center Inc

Key facts

NPI: 1649417759
Entity type: Organization (NPI type 2)
Primary specialty: Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name: AUNT MARTHAS YOUTH SERVICE CENTER INC
Practice address: 200 E Walnut St
Watseka, IL 60970-1356
Phone: (708) 747-7100
Fax: (708) 747-0710
NPI assigned: Jan 12, 2009
Organization subpart: No

Authorized official

Name: Mr. Christopher J Nordloh
Title: Cfo
Phone: (708) 747-7100

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Aunt Martha'S Health and Wellness, Inc. Federally Qualified Health Center (FQHC) · Chicago, IL · NPI 1811171143

CMS ownership 5% OR GREATER DIRECT OWNERSHIP INTEREST

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Aunt Martha'S Health and Wellness, Inc. Federally Qualified Health Center (FQHC) · Aurora, IL · NPI 1629118161

Same PAC ID 7214846922
Aunt Martha'S Health and Wellness, Inc. Federally Qualified Health Center (FQHC) · Chicago, IL · NPI 1811171143

Same PAC ID 7214846922

Medicare participation

Medicare fee-for-service enrollment: Enrolled in IL

Federally qualified health center certification: CCN 141121

Legal name: AUNT MARTHA'S YOUTH SERVICE CENTER, INC.
Doing business as: AUNT MARTHAS IROQUOIS COMMUNITY HEALTH CENTER
Certification status: Active
Provider type (POS): Federally qualified health center
Participating since: Jun 7, 2010
Last certification: Jun 7, 2010
Ownership / control type: For profit – corporation
Organization structure: Corporation · Proprietary
Incorporated: Aug 22, 1972 in IL
Enrollment address: 19990 Governors Hwy
Olympia Fields, IL 60461-1021

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Name	Role	Since
William John Wesender Individual	Corporate Director	Apr 15, 2010
Jessica Elinkowski Individual	Corporate Director	Apr 15, 2010
Wenjun Lu Individual	W-2 Managing Employee	Apr 15, 2010
Ellen W. Kaplan Individual	Corporate Director	Apr 15, 2010
John S Annis Individual	Corporate Director	Apr 15, 2010
Charles Gary Leofanti Individual	W-2 Managing Employee	Apr 15, 2010
Charles H. Childress Individual	Corporate Director	Apr 15, 2010
Sergio Berrios Individual	Corporate Director	Apr 15, 2010
Andrew Arthur Jones Individual	Corporate Director	Apr 15, 2010
Deborah Jean Watson Individual	Corporate Director	Apr 15, 2010
Chris Nordloh Individual	W-2 Managing Employee	Dec 1, 2010
Darryl S Stroud Individual	Corporate Director	Apr 15, 2010
Evonique Davis Individual	Corporate Director	Apr 15, 2010
Raul Garza Individual	W-2 Managing Employee	Apr 15, 2010

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

Facility	Type	Role	Since
Aunt Martha'S Youth Service Center, Inc. Chicago, IL · CCN 141083	Federally qualified health center	5% Or Greater Direct Ownership Interest	Apr 1, 2008

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
O20100607000566	IL	Part a Provider - Federally Qualified Health Center (FQHC)	7214846922	Practice locations: Olympia Fields, IL

National Provider Directory

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Federally Qualified Health Center (FQHC)	261QF0400X			Yes

Addresses

Primary practice location

200 E Walnut St
Watseka, IL 60970-1356

Mailing address

19990 Governors Hwy
Olympia Fields, IL 60461-1021
Phone (708) 747-7100

Other names

Aunt Marthas Iroquois Community Health Center Doing business as

Other providers in Watseka, IL

All providers in Watseka, IL · Federally Qualified Health Center (FQHC) in Illinois

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 22, 2011. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
Provider of Services files (CMS): certification status, beds and related CCNs.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.