Provider Demographics
NPI:1679550198
Name:LEAMONS AMBULANCE SERVICE, INC
Entity type:Organization
Organization Name:LEAMONS AMBULANCE SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:P
Authorized Official - Last Name:LEAMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-369-4512
Mailing Address - Street 1:210 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LENA
Mailing Address - State:IL
Mailing Address - Zip Code:61048-9770
Mailing Address - Country:US
Mailing Address - Phone:815-369-4512
Mailing Address - Fax:815-369-2309
Practice Address - Street 1:210 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LENA
Practice Address - State:IL
Practice Address - Zip Code:61048-9770
Practice Address - Country:US
Practice Address - Phone:815-369-4512
Practice Address - Fax:815-369-2309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1363341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid