Provider Demographics
NPI:1417472739
Name:CITY OF BENTON
Entity Type:Organization
Organization Name:CITY OF BENTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:COCKRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-439-2511
Mailing Address - Street 1:PO BOX 2122
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-1122
Mailing Address - Country:US
Mailing Address - Phone:734-479-6300
Mailing Address - Fax:734-479-6319
Practice Address - Street 1:107 N. MAPLE ST.
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812
Practice Address - Country:US
Practice Address - Phone:618-439-2511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-08
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0554963416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport