Provider Demographics
NPI:1467643320
Name:VILLAGE OF DETOUR
Entity Type:Organization
Organization Name:VILLAGE OF DETOUR
Other - Org Name:DETOUR AMBULANCE
Other - Org Type:Other Name
Authorized Official - Title/Position:CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-297-5471
Mailing Address - Street 1:260 S SUPERIOR STREET
Mailing Address - Street 2:PO BOX 397
Mailing Address - City:DETOUR
Mailing Address - State:MI
Mailing Address - Zip Code:49725
Mailing Address - Country:US
Mailing Address - Phone:906-297-5471
Mailing Address - Fax:906-297-2107
Practice Address - Street 1:206 S ONTARIO STREET
Practice Address - Street 2:
Practice Address - City:DETOUR
Practice Address - State:MI
Practice Address - Zip Code:49725
Practice Address - Country:US
Practice Address - Phone:906-297-5471
Practice Address - Fax:906-297-2107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI17 1002341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3001709Medicaid
MIOA70003OtherBLUE CROSS OF MICHIGAN