# GHOLSON FUNERAL HOME LTD

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

## Provider details

- **NPI number:** 1639241979
- **Authorized official:** J.B. GHOLSON (DIRECTOR)
- **Authorized official phone:** (618) 643-2321

## Contact information

- **Practice address:** 500 S WASHINGTON ST, MC LEANSBORO, IL 62859-1238
- **Practice address phone:** (618) 643-2321
- **Practice address fax:** (618) 643-2322
- **Mailing address:** 500 S WASHINGTON ST, MC LEANSBORO, IL 62859-1238
- **Mailing address phone:** (618) 643-2321
- **Mailing address fax:** (618) 643-2322

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3416L0300X | Land Ambulance | 5172 | IL | Yes |

## Other

- **Enumeration date:** 11/14/2006
- **Last updated:** 02/21/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0008470065 | BLUE CROSS BLUE SHIELD IL | IL |
| 01 | — | 590155125 | RAILROAD MEDICARE | IL |