1336214493 NPI number — CIVIL CITY OF LAKE STATION IND

Table of content: (NPI 1336214493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336214493 NPI number — CIVIL CITY OF LAKE STATION IND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CIVIL CITY OF LAKE STATION IND
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:
6
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:
1336214493
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1969 CENTRAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE STATION
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46405-2059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-962-2081
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1876 FAIRVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE STATION
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-962-8295
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FAZEKAS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
FIRE CHIEF
Authorized Official Telephone Number:
219-945-6629

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  0291 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000215119 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200262890A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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