Provider Demographics
NPI:1205852639
Name:VILLAGE OF CRETE
Entity type:Organization
Organization Name:VILLAGE OF CRETE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-672-5431
Mailing Address - Street 1:PO BOX 1053
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-2052
Mailing Address - Country:US
Mailing Address - Phone:708-478-5694
Mailing Address - Fax:
Practice Address - Street 1:524 W EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-2139
Practice Address - Country:US
Practice Address - Phone:708-672-5431
Practice Address - Fax:708-672-3920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL73143416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL278720500OtherDOL OWCP
IL9970504OtherBCBS
IL590001912OtherRR MEDICARE
IL=========OtherTRICARE NORTH
IL=========001Medicaid
IL590001912Medicare PIN
IL693960Medicare PIN