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General NPI Number Information
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NPI Number | 1457558520
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Entity Type | Organization
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Legal Business Name | ICWM, LLC
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Dates
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Enumeration Date | 06/30/2007
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Last Update Date | 02/21/2008
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Provider Practice Location Address
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Address Line | 59742 WREN LN
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City | SOUTH BEND
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State | IN
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Zip | 46614-4007
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Country | US
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Telephone | 574-231-1998
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Fax | 574-231-1997
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Provider Business Mailing Address
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Address Line | PO BOX 10037
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City | SOUTH BEND
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State | IN
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Zip | 46680-0037
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Country | US
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Telephone | 574-287-7068
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Fax | 574-287-7096
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. WALTER WILLARD BALLARD III
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Credential |
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Telephone | 574-383-1751
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number | USDOT 1427478 IN
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License Number State | IN
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