=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447594155
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BARTON W STONE JACKSONVILLE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2012
-----------------------------------------------------
Last Update Date | 10/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 873 GROVE ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62650-2828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-479-3400
-----------------------------------------------------
Fax | 217-243-8553
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 W JEFFERSON ST SUITE 401
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-3946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-828-4361
-----------------------------------------------------
Fax | 309-829-5477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXEC VP, CFO
-----------------------------------------------------
Name | DAVID UNDERWOOD
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 309-823-7139
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------