Provider Demographics
NPI:1124136320
Name:EARLVILLE COM FIRE PRO DIST
Entity type:Organization
Organization Name:EARLVILLE COM FIRE PRO DIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBULANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-970-4921
Mailing Address - Street 1:PO BOX 260
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-0260
Mailing Address - Country:US
Mailing Address - Phone:815-539-2468
Mailing Address - Fax:815-539-6427
Practice Address - Street 1:99 N. EAST ST
Practice Address - Street 2:
Practice Address - City:EARLVILLE
Practice Address - State:IL
Practice Address - Zip Code:60518-8232
Practice Address - Country:US
Practice Address - Phone:815-246-7095
Practice Address - Fax:815-246-7095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1 2554341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005032023OtherBLUE CROSS BLUE SHIELD
IL590000937OtherRAILROAD MEDICARE
IL362038712001Medicaid
IL590000937OtherRAILROAD MEDICARE