Provider Demographics
NPI:1770673170
Name:HENRY COMMUNITY AMBULANCE SERVICE
Entity Type:Organization
Organization Name:HENRY COMMUNITY AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-364-3323
Mailing Address - Street 1:216 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:HENRY
Mailing Address - State:IL
Mailing Address - Zip Code:61537-1325
Mailing Address - Country:US
Mailing Address - Phone:309-364-3323
Mailing Address - Fax:309-364-3320
Practice Address - Street 1:216 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:HENRY
Practice Address - State:IL
Practice Address - Zip Code:61537-1325
Practice Address - Country:US
Practice Address - Phone:309-364-3323
Practice Address - Fax:309-364-3320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225303416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL590003294OtherRAILROAD MEDICARE
IL590003294OtherRAILROAD MEDICARE
IL=========001Medicaid