Basic Information
Provider Information | |||||||||
NPI: | 1942507355 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FOX RIVER & COUNTRYSIDE FIRE/RESCUE DISTRICT | ||||||||
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: | 6305302988 | ||||||||
FaxNumber: | 6309032830 | ||||||||
Practice Location | |||||||||
Address1: | 35W350 CARL LEE ROAD | ||||||||
Address2: |   | ||||||||
City: | ST CHARLES | ||||||||
State: | IL | ||||||||
PostalCode: | 60175 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6305843473 | ||||||||
FaxNumber: | 6305848266 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2011 | ||||||||
LastUpdateDate: | 02/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NIXON | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | FIRE CHIEF | ||||||||
AuthorizedOfficialTelephone: | 6305843473 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X |   |   | Y |   | Transportation Services | Ambulance |   |
ID Information
ID | Type | State | Issuer | Description | IL5881 | 01 | IL | MEDICARE | OTHER | ========= | 01 | IL | PUBLIC AID | OTHER |