Healthcare Provider Details

I. General information

NPI: 1801801782
Provider Name (Legal Business Name): BRAIDWOOD VOLUNTEER FIRE DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W MAIN ST
BRAIDWOOD IL
60408-1919
US

IV. Provider business mailing address

395 WEST LAKE STREET ATTN: KIMBERLY FULLER
ELMHURST IL
60126-1508
US

V. Phone/Fax

Practice location:
  • Phone: 815-458-2000
  • Fax: 815-458-3636
Mailing address:
  • Phone: 630-903-2372
  • Fax: 630-903-2830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number77151
License Number StateIL

VIII. Authorized Official

Name: KEN HEBERER
Title or Position: FIRE CHIEF
Credential:
Phone: 815-458-2000