Healthcare Provider Details

I. General information

NPI: 1952351330
Provider Name (Legal Business Name): CITY OF GRAYVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 S COURT ST
GRAYVILLE IL
62844-1509
US

IV. Provider business mailing address

122 SOUTH COURT
GRAYVILLE IL
62844
US

V. Phone/Fax

Practice location:
  • Phone: 618-375-3671
  • Fax: 618-375-7869
Mailing address:
  • Phone: 618-375-3671
  • Fax: 618-375-7869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number5-51208
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: CINDY ANNE JUDGE
Title or Position: PAYROLL CLERK
Credential:
Phone: 618-375-3671