Provider Demographics
NPI:1659371458
Name:VILLAGE OF DIXMOOR
Entity Type:Organization
Organization Name:VILLAGE OF DIXMOOR
Other - Org Name:DIXMOOR FIRE DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNELL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-389-9441
Mailing Address - Street 1:166 W 145TH ST
Mailing Address - Street 2:
Mailing Address - City:DIXMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60426-1068
Mailing Address - Country:US
Mailing Address - Phone:708-389-9441
Mailing Address - Fax:708-388-2439
Practice Address - Street 1:166 W 145TH ST
Practice Address - Street 2:
Practice Address - City:DIXMOOR
Practice Address - State:IL
Practice Address - Zip Code:60426-1068
Practice Address - Country:US
Practice Address - Phone:708-389-9441
Practice Address - Fax:708-388-2439
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VILLAGE OF DIXMOOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-22
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL781673416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
789470Medicare ID - Type Unspecified