Provider Demographics
NPI:1184671448
Name:FOX LAKE COMMUNITY FIRE ASSOCIATION
Entity Type:Organization
Organization Name:FOX LAKE COMMUNITY FIRE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTTKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-928-6115
Mailing Address - Street 1:W8542 LAUREL HILL RD
Mailing Address - Street 2:
Mailing Address - City:FOX LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53933-9739
Mailing Address - Country:US
Mailing Address - Phone:920-928-6115
Mailing Address - Fax:
Practice Address - Street 1:246 E STATE ST
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:WI
Practice Address - Zip Code:53933-8027
Practice Address - Country:US
Practice Address - Phone:920-928-6115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60001393416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41314800Medicaid
WI41314800OtherWISCONSIN RENAL PROGRAM
WI41314800OtherH.I.R.S.P.