Basic Information
| Provider Information | |||||||||
| NPI: | 1801820873 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAUCONDA FIRE DEPARTMENT | ||||||||
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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: | 109 W LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | WAUCONDA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600842453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475262821 | ||||||||
| FaxNumber: | 8475262836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | DATO | ||||||||
| AuthorizedOfficialFirstName: | DAVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 8475262821 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 7262 | IL | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 4970712 | 01 | IL | BCBS | OTHER |