1700830973 NPI number — VILLAGE NORTH FOND DU LAC

Table of content: (NPI 1700830973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700830973 NPI number — VILLAGE NORTH FOND DU LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VILLAGE NORTH FOND DU LAC
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:
NORTH FOND DU LAC EMS
Provider Other Organization Name Type Code:
3
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:
1700830973
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 GARFIELD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH FOND DU LAC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54937-1387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 GARFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH FOND DU LAC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54937-1387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-929-3954
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HORNUNG
Authorized Official First Name:
CHUCK
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF
Authorized Official Telephone Number:
920-929-3954

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1022683 . This is a "PHYSICIAN'S PLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 41327400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000082921 . This is a "ADVOCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1962 . This is a "NETWORK HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: WI0101 . This is a "JOHN DEERE" identifier . This identifiers is of the category "OTHER".




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