=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396879896
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELAVAN AMBULANCE SERVICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 05/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 S PINE STREET
-----------------------------------------------------
City | DELAVAN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61734-0747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-244-7420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 747 510 S PINE STREET
-----------------------------------------------------
City | DELAVAN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61734-0747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-244-7420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER
-----------------------------------------------------
Name | CINDY SPRINGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-244-7420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 22532
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------