Provider Demographics
NPI:1114919081
Name:POLK JACKSON PERRY VOLUNTEER FIREFIGHTERS & SQUADPERSONS ASSICI
Entity Type:Organization
Organization Name:POLK JACKSON PERRY VOLUNTEER FIREFIGHTERS & SQUADPERSONS ASSICI
Other - Org Name:POLK JACKSON PERRY FIRE DISTRICT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FISCAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-651-1304
Mailing Address - Street 1:10361 SPARTAN DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-1220
Mailing Address - Country:US
Mailing Address - Phone:800-962-1484
Mailing Address - Fax:513-772-4464
Practice Address - Street 1:209 E CONGRESS ST
Practice Address - Street 2:
Practice Address - City:POLK
Practice Address - State:OH
Practice Address - Zip Code:44866-9701
Practice Address - Country:US
Practice Address - Phone:419-945-2681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0203630503416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000272999OtherANTHEM
OH2385333Medicaid
OH000000272999OtherANTHEM
OH2385333Medicaid