MEDICARE: CROWN MEDICARE INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)		IL

General Provider Information

NPI Number	:	1780844910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN MEDICARE INC.

Provider Business Mailing Address
First Line	:	2243 S 24TH AVE
Second Line	:
City	:	BROADVIEW
State	:	IL
Zip	:	60155-3820
Country	:	US
Telephone Number	:	708-338-3305
Fax Number	:	708-338-3306

Provider Business Practice Location Address
First Line	:	2243 S 24TH AVE
Second Line	:
City	:	BROADVIEW
State	:	IL
Zip	:	60155-3820
Country	:	US
Telephone Number	:	708-338-3305
Fax Number	:	708-338-3306

Authorized Official
Title or Position	:	CEO
Name	:	MR. ADEREMI OTESILE
Credential	:
Telephone Number	:	708-338-3305

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	06/11/2008

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