Provider Demographics
NPI:1447610381
Name:MATHERS CLINIC, LLC
Entity Type:Organization
Organization Name:MATHERS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAMESH
Authorized Official - Middle Name:B
Authorized Official - Last Name:VEMURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-444-9999
Mailing Address - Street 1:145 S VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7226
Mailing Address - Country:US
Mailing Address - Phone:815-444-9999
Mailing Address - Fax:815-986-1363
Practice Address - Street 1:145 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7226
Practice Address - Country:US
Practice Address - Phone:815-444-9999
Practice Address - Fax:815-986-1363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054365251S00000X
IL261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)