Provider Demographics
NPI:1033153325
Name:VILLAGE OF SOUTH CHICAGO HEIGHTS
Entity type:Organization
Organization Name:VILLAGE OF SOUTH CHICAGO HEIGHTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:VLIETSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-755-9589
Mailing Address - Street 1:PO BOX 1368
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126
Mailing Address - Country:US
Mailing Address - Phone:630-530-2988
Mailing Address - Fax:630-832-9750
Practice Address - Street 1:3317 CHICAGO ROAD
Practice Address - Street 2:
Practice Address - City:SOUTH CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-4815
Practice Address - Country:US
Practice Address - Phone:708-755-1880
Practice Address - Fax:708-755-7186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL89233416L0300X
IL3416L0300X, 341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9930119OtherBCBS
IL590013880OtherRR MEDICARE
IL=========OtherTRICARE NORTH
IL590013880OtherRR MEDICARE
IL9930119OtherBCBS
IL365660Medicare PIN