=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891459079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED MEDICAL TRANSPORT EAST INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2021
-----------------------------------------------------
Last Update Date | 10/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 S NEIL ST
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61820-5218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-999-4049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1718 N STERLING AVE
-----------------------------------------------------
City | WEST PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61604-3831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-494-6203
-----------------------------------------------------
Fax | 309-494-6214
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | GREGORY CHANCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-679-4192
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------