Healthcare Provider Details

I. General information

NPI: 1700871910
Provider Name (Legal Business Name): FORMAN AMBULANCE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N BROADWAY
MANITO IL
61546-0648
US

IV. Provider business mailing address

PO BOX 648
MANITO IL
61546-0648
US

V. Phone/Fax

Practice location:
  • Phone: 309-968-6902
  • Fax: 309-968-6649
Mailing address:
  • Phone: 309-968-6902
  • Fax: 309-968-6649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416A0800X
TaxonomyAir Ambulance
License Number1660298
License Number StateIL

VIII. Authorized Official

Name: SHERON KAYE BORTELL
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 309-968-6902