=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356439152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON TOWNSHIP TRUSTEES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 05/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7383 FULTON DR NW
-----------------------------------------------------
City | MASSILLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44646-9393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-834-3950
-----------------------------------------------------
Fax | 330-834-3958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5735 WALES AVE NW
-----------------------------------------------------
City | MASSILLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44646-9097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-832-7416
-----------------------------------------------------
Fax | 330-832-5936
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FIRE CHIEF
-----------------------------------------------------
Name | TIMOTHY G BERCZIK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-834-3952
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 02-0301400
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------