=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326123613
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY OF OFALLON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 09/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 285 N 7 HILLS RD
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-4110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-538-8278
-----------------------------------------------------
Fax | 580-628-2273
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 285 N 7 HILLS RD
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-4110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-538-8278
-----------------------------------------------------
Fax | 580-628-2273
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISOR
-----------------------------------------------------
Name | JIM HOLLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-538-8278
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 4865
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------