Aunt Marthas Youth Service Center Inc

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

AUNT MARTHAS YOUTH SERVICE CENTER INC

Doing business as

Aunt Marthas Iroquois Community Health Center

Practice address

200 E Walnut St
Watseka, IL 60970-1356

Phone

(708) 747-7100

Fax

(708) 747-0710

NPI assigned

Jan 12, 2009

Last updated

Mar 22, 2011By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Christopher J Nordloh

Title

Cfo

Phone

(708) 747-7100

Specialties & licenses 1

Addresses

Other names 1

• Aunt Marthas Iroquois Community Health Center Doing business as

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1649417759. Details of each certification follow.

• CCN 141121 Federally qualified health center · Active · Details

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

CorporationProprietary

Incorporated

Aug 22, 1972 in IL

Enrollment address

19990 Governors Hwy
Olympia Fields, IL 60461-1021

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.

  dba Aunt Martha's Aurora Health and Outreach Center

  • Federally Qualified Health Center (FQHC)
  • Aurora, IL
  • NPI 1629118161

  7214846922

  Same PAC ID
• Aunt Martha's Health and Wellness, Inc.

  dba Aunt Martha's Southeast Side Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
  • NPI 1811171143

  7214846922

  Same PAC ID

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.

All facility ownership & control disclosures 1

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

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.

  dba Aunt Martha's Southeast Side Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
  • NPI 1811171143

  5% Or Greater Direct Ownership Interest

  CMS ownership

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1231718400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1300752000000",
    "number": "1649417759",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "19990 GOVERNORS HWY",
            "city": "OLYMPIA FIELDS",
            "state": "IL",
            "postal_code": "604611021",
            "telephone_number": "708-747-7100",
            "fax_number": "708-747-0710"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 E WALNUT ST",
            "city": "WATSEKA",
            "state": "IL",
            "postal_code": "609701356",
            "telephone_number": "708-747-7100",
            "fax_number": "708-747-0710"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AUNT MARTHAS YOUTH SERVICE CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-01-12",
        "last_updated": "2011-03-22",
        "status": "A",
        "authorized_official_last_name": "NORDLOH",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "708-747-7100",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Aunt Marthas Iroquois Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jaelyn Lois Anderson, FNP-BC
• Steven Ray Anderson
• Arcadia Care Watseka LLC (Arcadia Care Watseka)
• Arcadia Care Watseka LLC (Arcadia Care Watseka)
• Brandi Arseneau, MSW
• Iftekhar A. Awan, MD
• Hamzeh Omar Badwan I, MD
• Janelle Bagley
• Holly Elizabeth Bandur
• Tasha Leroyce Banks, MS

• Federally Qualified Health Center (FQHC) in Watseka, IL
• Providers in Watseka, IL by specialty
• Federally Qualified Health Center (FQHC) in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 22, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.