=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538170840
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CICERO TOWNSHIP VOLUNTEER FIRE DEPARTMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 06/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 DEVELOPMENT DR
-----------------------------------------------------
City | TIPTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46072-1072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-675-8004
-----------------------------------------------------
Fax | 765-675-3528
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2915
-----------------------------------------------------
City | ELKHART
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46515-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-293-3030
-----------------------------------------------------
Fax | 574-294-1345
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF
-----------------------------------------------------
Name | MICHAEL J. PRATT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 765-675-8004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 0083
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------