Healthcare Provider Details

I. General information

NPI: 1427189604
Provider Name (Legal Business Name): CORPORATION OF VILLAGE OF PORT WILLIAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 05/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 SECOND ST
PORT WILLIAM OH
45164
US

IV. Provider business mailing address

PO BOX 263
WILMINGTON OH
45177-0263
US

V. Phone/Fax

Practice location:
  • Phone: 937-302-7010
  • Fax: 937-486-5300
Mailing address:
  • Phone: 937-424-3701
  • Fax: 937-291-2971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number02-0327100
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number StateNULL

VIII. Authorized Official

Name: KEN IANSON
Title or Position: MAYOR
Credential:
Phone: 937-302-7010