Provider Demographics
NPI:1639614175
Name:MATHERS RECOVERY LLC
Entity Type:Organization
Organization Name:MATHERS RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAMESH
Authorized Official - Middle Name:
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 1:420 AIRPORT RD STE C
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9329
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:2016-12-19
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2800X, 261QM2800X
IL261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder