Provider Demographics
NPI:1366487753
Name:SISTER LAKES FIRE DEPARTMENT
Entity Type:Organization
Organization Name:SISTER LAKES FIRE DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-424-3145
Mailing Address - Street 1:92280 COUNTY ROAD 690
Mailing Address - Street 2:
Mailing Address - City:DOWAGIAC
Mailing Address - State:MI
Mailing Address - Zip Code:49047-9035
Mailing Address - Country:US
Mailing Address - Phone:269-424-3145
Mailing Address - Fax:269-424-5560
Practice Address - Street 1:92280 COUNTY ROAD 690
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-9035
Practice Address - Country:US
Practice Address - Phone:269-424-3145
Practice Address - Fax:269-424-5560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI801005341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2789837Medicaid
590H000014OtherBCBS
MI2789837Medicaid
MI0H00014Medicare PIN