1568475895 NPI number — VILLAGE OF LISBON

Table of content: (NPI 1568475895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568475895 NPI number — VILLAGE OF LISBON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VILLAGE OF LISBON
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:
1568475895
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:
W234 N8676 WOODSIDE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUSSEX
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53089-1545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-246-6100
Provider Business Mailing Address Fax Number:
262-820-2023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N72 W24958 GOOD HOPE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUSSEX
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-538-3902
Provider Business Practice Location Address Fax Number:
262-820-2030
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NICKOLAUS
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
262-246-6100

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  6001261 , 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: 41315400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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