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General NPI Number Information
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NPI Number | 1366599854
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Entity Type | Organization
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Legal Business Name | STEPHEN & FRED SHRADER PTR
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Dates
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Enumeration Date | 01/05/2007
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Last Update Date | 01/24/2012
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Provider Practice Location Address
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Address Line | 204 N LOCUST ST
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City | ARCOLA
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State | IL
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Zip | 61910-1407
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Country | US
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Telephone | 217-268-4848
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 277 204 N. LOCUST ST
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City | ARCOLA
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State | IL
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Zip | 61910-0277
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Country | US
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Telephone | 217-268-4848
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. CONNIE SHRADER
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Credential |
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Telephone | 217-268-4848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 341600000X
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Taxonomy Name | Ambulance
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License Number | 670002
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License Number State | IL
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