Provider Demographics
NPI:1972811743
Name:ILLINOIS VALLEY CITY CAB, INC
Entity type:Organization
Organization Name:ILLINOIS VALLEY CITY CAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHOLDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-252-5513
Mailing Address - Street 1:206 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-2385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 3RD ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-2385
Practice Address - Country:US
Practice Address - Phone:815-252-5513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid