# CITY OF COUNTRY CLUB HILLS

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1265485007
- **Authorized official:** MR. MICHELLE COON (FIRE CHIEF)
- **Authorized official phone:** (708) 478-5694

## Contact information

- **Practice address:** 4200 W. 183RD ST, COUNTRY CLUB HILLS, IL 60478-5311
- **Practice address phone:** (708) 798-8488
- **Practice address fax:** (708) 798-8555
- **Mailing address:** PO BOX 1053, MOKENA, IL 60448-2052
- **Mailing address phone:** (708) 478-5694

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3416L0300X | Land Ambulance | 78166 | IL | Yes |

## Other

- **Enumeration date:** 05/19/2006
- **Last updated:** 12/10/2019

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 016-70820 | BLUE CROSS BLUE SHIELD | IL |
| 01 | — | P00151630 | RAILROAD MEDICARE | IL |