1780632497 NPI number — STONE BANK VOLUNTEER FIRE

Table of content: (NPI 1780632497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780632497 NPI number — STONE BANK VOLUNTEER FIRE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONE BANK VOLUNTEER FIRE
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:
1780632497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 72140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDARBURG
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53012-7340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-375-9610
Provider Business Mailing Address Fax Number:
262-375-9608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W335N7107 STONEBANK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCONOMOWOC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53066-1407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-966-2414
Provider Business Practice Location Address Fax Number:
262-966-2831
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLOKOW
Authorized Official First Name:
MARK
Authorized Official Middle Name:
G
Authorized Official Title or Position:
CHIEF
Authorized Official Telephone Number:
262-966-2414

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  6001211 , 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: 41359600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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