Basic Information
Provider Information | |||||||||
NPI: | 1104811967 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VILLAGE OF BOLINGBROOK ILLINOIS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 395 WEST LAKE STREET | ||||||||
Address2: |   | ||||||||
City: | ELMHURST | ||||||||
State: | IL | ||||||||
PostalCode: | 601261508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6309032372 | ||||||||
FaxNumber: | 6309032830 | ||||||||
Practice Location | |||||||||
Address1: | 375 W BRIARCLIFF RD | ||||||||
Address2: |   | ||||||||
City: | BOLINGBROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 604403825 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302268540 | ||||||||
FaxNumber: | 6307594016 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2005 | ||||||||
LastUpdateDate: | 04/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARZA | ||||||||
AuthorizedOfficialFirstName: | TRINIDAD | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | DEPUTY FIRE CHIEF | ||||||||
AuthorizedOfficialTelephone: | 6302268552 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X |   |   | Y |   | Transportation Services | Ambulance | Land Transport |
ID Information
ID | Type | State | Issuer | Description | 9915055 | 01 | IL | BCBS OF IL | OTHER | 590005580 | 01 |   | RAILROAD MEDICARE | OTHER |