Provider Demographics
NPI:1912926056
Name:COUNTY OF MOULTRIE
Entity Type:Organization
Organization Name:COUNTY OF MOULTRIE
Other - Org Name:SULLIVAN FIRE AMBULANCE DISTRICT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER S.F.P.D.
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-728-8714
Mailing Address - Street 1:115 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-1908
Mailing Address - Country:US
Mailing Address - Phone:217-728-8714
Mailing Address - Fax:217-728-7402
Practice Address - Street 1:115 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-1908
Practice Address - Country:US
Practice Address - Phone:217-728-8714
Practice Address - Fax:217-728-7402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001341600000X
IL16599653416A0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid