Provider Demographics
NPI:1265500771
Name:ERICKSON AUTO TRIM, INC.
Entity Type:Organization
Organization Name:ERICKSON AUTO TRIM, INC.
Other - Org Name:ERICKSON MOBILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KUDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-554-1202
Mailing Address - Street 1:2210 LATHROP AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4137
Mailing Address - Country:US
Mailing Address - Phone:262-554-1202
Mailing Address - Fax:262-554-9232
Practice Address - Street 1:2210 LATHROP AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-4137
Practice Address - Country:US
Practice Address - Phone:262-554-1202
Practice Address - Fax:262-554-9232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41565000Medicaid
WI5279570001Medicare NSC