Healthcare Provider Details

I. General information

NPI: 1447621875
Provider Name (Legal Business Name): A-ADVANTAGE AMBULANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 W 190TH ST SUITE B-10
MOKENA IL
60448-5604
US

IV. Provider business mailing address

9850 W 190TH ST STE B-10
MOKENA IL
60448-5604
US

V. Phone/Fax

Practice location:
  • Phone: 708-995-1187
  • Fax: 708-995-7230
Mailing address:
  • Phone: 708-995-1187
  • Fax: 708-995-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number8061
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number8061
License Number StateIL

VIII. Authorized Official

Name: KIM DIETZ
Title or Position: DIRECTOR OF PATIENT ACCOUNTS
Credential:
Phone: 708-995-1187