Healthcare Provider Details

I. General information

NPI: 1770540049
Provider Name (Legal Business Name): ANTIOCH RESCUE SQUAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 HOLBECK DR
ANTIOCH IL
60002-1270
US

IV. Provider business mailing address

PO BOX 457
WHEELING IL
60090-0457
US

V. Phone/Fax

Practice location:
  • Phone: 847-395-0302
  • Fax: 630-903-2830
Mailing address:
  • Phone: 847-577-8811
  • Fax: 847-577-3518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number87264
License Number StateIL

VIII. Authorized Official

Name: WAYNE SOBCZAK
Title or Position: RESCUE CHIEF
Credential:
Phone: 847-395-1010