Healthcare Provider Details

I. General information

NPI: 1639241979
Provider Name (Legal Business Name): GHOLSON FUNERAL HOME LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S WASHINGTON ST
MC LEANSBORO IL
62859-1238
US

IV. Provider business mailing address

500 S WASHINGTON ST
MC LEANSBORO IL
62859-1238
US

V. Phone/Fax

Practice location:
  • Phone: 618-643-2321
  • Fax: 618-643-2322
Mailing address:
  • Phone: 618-643-2321
  • Fax: 618-643-2322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number5172
License Number StateIL

VIII. Authorized Official

Name: J.B. GHOLSON
Title or Position: DIRECTOR
Credential:
Phone: 618-643-2321