Provider Demographics
NPI:1750142204
Name:MAINE WEST SCHOOL BASED HEALTH CENTER
Entity type:Organization
Organization Name:MAINE WEST SCHOOL BASED HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:B
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:801-803-9592
Mailing Address - Street 1:1755 S WOLF RD STE E103
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-1923
Mailing Address - Country:US
Mailing Address - Phone:847-803-5591
Mailing Address - Fax:847-825-4060
Practice Address - Street 1:1755 S WOLF RD STE E103
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-1923
Practice Address - Country:US
Practice Address - Phone:847-803-5591
Practice Address - Fax:847-825-4060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health