=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346542339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY OF LASALLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2010
-----------------------------------------------------
Last Update Date | 12/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 745 2ND ST
-----------------------------------------------------
City | LA SALLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61301-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-223-4579
-----------------------------------------------------
Fax | 815-223-0857
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 745 2ND ST
-----------------------------------------------------
City | LA SALLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61301-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-223-4579
-----------------------------------------------------
Fax | 815-223-0857
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FIRE CHIEF
-----------------------------------------------------
Name | MR. ANDREW ANTONE BACIDORE
-----------------------------------------------------
Credential | EMT-BASIC
-----------------------------------------------------
Telephone | 815-223-0834
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 022482
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------