=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134131949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STARK COUNTY AMBULANCE SERVICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2006
-----------------------------------------------------
Last Update Date | 08/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 N FRANKLIN ST
-----------------------------------------------------
City | TOULON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-286-7154
-----------------------------------------------------
Fax | 309-286-0028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 NORTH FRANKLIN STREET POB 236
-----------------------------------------------------
City | TOULON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61483-0236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-286-7154
-----------------------------------------------------
Fax | 309-286-0028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DIRECTOR
-----------------------------------------------------
Name | MR. JAMES LEONARD ROESNER
-----------------------------------------------------
Credential | CEO
-----------------------------------------------------
Telephone | 309-286-7154
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 2574
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 2574
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------