1457689051 NPI number — LAKE COUNTRY FIRE & RESCUE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457689051 NPI number — LAKE COUNTRY FIRE & RESCUE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE COUNTRY FIRE & RESCUE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457689051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 457
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHEELING
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60090-0457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-577-8811
Provider Business Mailing Address Fax Number:
847-577-3518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELAFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53018-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-646-6235
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
JACK
Authorized Official Middle Name:
F
Authorized Official Title or Position:
FIRE CHIEF
Authorized Official Telephone Number:
262-646-6235

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  6604884 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1457689051 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1457689051 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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