Provider Demographics
NPI:1730100942
Name:VILLAGE OF BROADVIEW
Entity Type:Organization
Organization Name:VILLAGE OF BROADVIEW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-343-6124
Mailing Address - Street 1:395 WEST LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1508
Mailing Address - Country:US
Mailing Address - Phone:630-903-2372
Mailing Address - Fax:630-903-2830
Practice Address - Street 1:2350 S 25TH AVE
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-3827
Practice Address - Country:US
Practice Address - Phone:708-343-6124
Practice Address - Fax:708-204-8918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL880553416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL590007932OtherRAILROAD MEDICARE
IL016-71276OtherBLUE CROSS BLUE SHIELD
IL590007932OtherRAILROAD MEDICARE
IL590007932OtherRAILROAD MEDICARE