Provider Demographics
NPI:1619019072
Name:HEYWORTH AMBULANCE SERVICE
Entity Type:Organization
Organization Name:HEYWORTH AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS CAPTAIN
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOWERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-261-3126
Mailing Address - Street 1:PO BOX 258
Mailing Address - Street 2:707 S VINE ST
Mailing Address - City:HEYWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:61745-0258
Mailing Address - Country:US
Mailing Address - Phone:309-473-2149
Mailing Address - Fax:309-473-2473
Practice Address - Street 1:707 S VINE ST
Practice Address - Street 2:
Practice Address - City:HEYWORTH
Practice Address - State:IL
Practice Address - Zip Code:61745-0258
Practice Address - Country:US
Practice Address - Phone:309-473-2149
Practice Address - Fax:309-473-2473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL267373416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL590013395OtherPALMETTO GBA
IL=========001Medicaid
IL=========TOtherBLUE CROSS BLUE SHIELD
IL273600Medicare ID - Type Unspecified