1366487753 NPI number — SISTER LAKES FIRE DEPARTMENT

Table of content: (NPI 1366487753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366487753 NPI number — SISTER LAKES FIRE DEPARTMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SISTER LAKES FIRE DEPARTMENT
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:
1366487753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
92280 COUNTY ROAD 690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOWAGIAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49047-9035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-424-3145
Provider Business Mailing Address Fax Number:
269-424-5560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
92280 COUNTY ROAD 690
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOWAGIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49047-9035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-424-3145
Provider Business Practice Location Address Fax Number:
269-424-5560
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TIDEY
Authorized Official First Name:
GAYLE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
269-424-3145

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  801005 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2789837 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 590H000014 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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