Provider Demographics
NPI:1407008998
Name:THE ILLINOIS MEDICAL ASSISTANCE TREATMENT PROGRAM LLC
Entity Type:Organization
Organization Name:THE ILLINOIS MEDICAL ASSISTANCE TREATMENT PROGRAM LLC
Other - Org Name:GREEN DRAGONFLY
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-360-1019
Mailing Address - Street 1:1738 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-5137
Mailing Address - Country:US
Mailing Address - Phone:847-360-1019
Mailing Address - Fax:847-360-6277
Practice Address - Street 1:1738 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5137
Practice Address - Country:US
Practice Address - Phone:847-360-1019
Practice Address - Fax:847-360-6277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA27740001A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center