Healthcare Provider Details

I. General information

NPI: 1265485007
Provider Name (Legal Business Name): CITY OF COUNTRY CLUB HILLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W. 183RD ST
COUNTRY CLUB HILLS IL
60478-5311
US

IV. Provider business mailing address

PO BOX 1053
MOKENA IL
60448-2052
US

V. Phone/Fax

Practice location:
  • Phone: 708-798-8488
  • Fax: 708-798-8555
Mailing address:
  • Phone: 708-478-5694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number78166
License Number StateIL

VIII. Authorized Official

Name: MR. MICHELLE COON
Title or Position: FIRE CHIEF
Credential:
Phone: 708-478-5694