=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427063130
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VILLAGE OF LA GRANGE PARK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 06/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 447 N CATHERINE AVE
-----------------------------------------------------
City | LA GRANGE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60526-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-354-0225
-----------------------------------------------------
Fax | 708-482-4425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 457
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60090-0457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-577-8811
-----------------------------------------------------
Fax | 847-577-7967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FIRE CHIEF
-----------------------------------------------------
Name | DEAN MAGGOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-354-0225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 8305
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------