Healthcare Provider Details

I. General information

NPI: 1023219094
Provider Name (Legal Business Name): TRI DISTRICT EMERGENCY AMBULANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7563 IL ROUTE 75
ROCK CITY IL
61070-0117
US

IV. Provider business mailing address

P.O. BOX 117 7563 IL ROUTE 75
ROCK CITY IL
61070-0117
US

V. Phone/Fax

Practice location:
  • Phone: 815-865-5153
  • Fax: 815-865-5153
Mailing address:
  • Phone: 815-865-5153
  • Fax: 815-865-5153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number01103601
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number
License Number State

VIII. Authorized Official

Name: EDWARD L KOELLING
Title or Position: PRESIDENT / SUPERVISOR
Credential:
Phone: 815-865-5153