=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003914540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINGREE GROVE & C SIDE FPD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 09/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39W160 PLANK RD
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123-8002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-436-5335
-----------------------------------------------------
Fax | 847-436-6420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6253
-----------------------------------------------------
City | CAROL STREAM
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60197-6253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-530-2988
-----------------------------------------------------
Fax | 630-832-9750
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FIRE CHIEF
-----------------------------------------------------
Name | KIERAN STOUT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-741-3151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 97907
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------