Provider Demographics
NPI:1245488857
Name:VILLAGE OF SOUTH JACKSONVILLE
Entity type:Organization
Organization Name:VILLAGE OF SOUTH JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:HICKOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-245-4803
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62663-0042
Mailing Address - Country:US
Mailing Address - Phone:217-587-4761
Mailing Address - Fax:217-587-2101
Practice Address - Street 1:301 DEWEY DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3206
Practice Address - Country:US
Practice Address - Phone:217-245-4803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL341600000X3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport