=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679715411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPRON RESCUE SQUAD DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2009
-----------------------------------------------------
Last Update Date | 11/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 W MAIN ST
-----------------------------------------------------
City | CAPRON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61012-7718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-943-2402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 422
-----------------------------------------------------
City | CAPRON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61012-0422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-569-2818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT CHIEF
-----------------------------------------------------
Name | TONY STEPANSKY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-569-2818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 011025
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------