1629051412 NPI number — VILLAGE OF MUKWONAGO

Table of content: (NPI 1629051412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629051412 NPI number — VILLAGE OF MUKWONAGO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VILLAGE OF MUKWONAGO
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:
1629051412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6400 INDUSTRIAL LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53129-2452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-423-4100
Provider Business Mailing Address Fax Number:
414-423-4134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 RIVERCREST CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUKWONAGO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53149-1759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-363-6426
Provider Business Practice Location Address Fax Number:
262-363-6454
Provider Enumeration Date:
11/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROLFE
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
FIRE CHIEF
Authorized Official Telephone Number:
262-363-6426

Provider Taxonomy Codes

  • Taxonomy code: 341600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 41339900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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