Basic Information
| Provider Information | |||||||||
| NPI: | 1144235854 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE OF LAKE ZURICH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600900457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475778811 | ||||||||
| FaxNumber: | 8475777967 | ||||||||
| Practice Location | |||||||||
| Address1: | 321 S BUESCHING RD | ||||||||
| Address2: | |||||||||
| City: | LAKE ZURICH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600472535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475405070 | ||||||||
| FaxNumber: | 8477261644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | MASTANDREA | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8475405070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 7260 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 132869200 | 01 | IL | DOL OWCP | OTHER | 4970844 | 01 | IL | BCBS | OTHER | 590028107 | 01 | IL | RR MEDICARE | OTHER |