Provider Demographics
NPI:1114970159
Name:TOWN OF BRAZEAU
Entity Type:Organization
Organization Name:TOWN OF BRAZEAU
Other - Org Name:TOWN OF BRAZEAU RESCUE SQUAD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-897-2793
Mailing Address - Street 1:9151 GRAVEL LN
Mailing Address - Street 2:
Mailing Address - City:LENA
Mailing Address - State:WI
Mailing Address - Zip Code:54139-9774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12071 PARKWAY RD
Practice Address - Street 2:
Practice Address - City:POUND
Practice Address - State:WI
Practice Address - Zip Code:54161-8707
Practice Address - Country:US
Practice Address - Phone:920-897-2793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41317700OtherHIRSP
12916OtherNETWORK HEALTH
WI41317700Medicaid
WI0101OtherJOHN DEERE
000080014OtherADVOCARE MCHMO
=========012OtherVALLEY HEALTH PLAN
=========012OtherBCBS
=========012OtherBCBS