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Organization
COUNTY OF PULASKI
Active
Organization
COUNTY OF PULASKI
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TRACIE DAWN HAFFORD (DIRECTOR)
(314) 677-0185
Entity
Organization
Contact information
Practice address
75 CAMO CLAD DR, PULASKI COUNTY AMBULANCE, MOUNDS, IL 62964
(618) 342-6209
(618) 342-6254
Mailing address
PO BOX 52, MOUNDS, IL 62964-0052
(618) 342-6209
(618) 342-6254
Taxonomy
Speciality
Code
Description
License number
State
341600000X
Ambulance
—
NULL
3416L0300X
Land Ambulance
Primary
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
07770390
BLUE CROSS BLUE SHIELD
IL
05
—
371076724001
—
IL
01
—
590000202
RAIL ROAD MEDICARE
IL
Enumeration date
09/22/2006
Last updated
08/11/2022
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