Provider Demographics
NPI:1629014774
Name:STOCKTON FIRE PROTECTION DIST
Entity Type:Organization
Organization Name:STOCKTON FIRE PROTECTION DIST
Other - Org Name:STOCKTON COMMUNITY AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HEIDENREICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHRN
Authorized Official - Phone:815-947-3023
Mailing Address - Street 1:113 E QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61085-1327
Mailing Address - Country:US
Mailing Address - Phone:815-947-3500
Mailing Address - Fax:815-947-9102
Practice Address - Street 1:113 E QUEEN ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:IL
Practice Address - Zip Code:61085-1327
Practice Address - Country:US
Practice Address - Phone:815-947-3500
Practice Address - Fax:815-947-9102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL100803146M00000X, 146N00000X, 3416L0300X
IL100802146M00000X, 146N00000X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, IntermediateGroup - Single Specialty
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty
No3416L0300XTransportation ServicesAmbulanceLand TransportGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid