=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407984297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF JOHNSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 05/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 INDUSTRIAL DRIVE
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62995-0038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-658-2131
-----------------------------------------------------
Fax | 618-658-8134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 155 INDUSTRIAL DRIVE P.O. BOX 38
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62995-0038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-658-2131
-----------------------------------------------------
Fax | 618-658-8134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. WENDI BAILEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-658-2131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 55018
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------