Provider Demographics
NPI:1508069923
Name:KICKAPOO VALLEY RESCUE SQUAD INC
Entity Type:Organization
Organization Name:KICKAPOO VALLEY RESCUE SQUAD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SADIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-606-3932
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:VIOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54664-0095
Mailing Address - Country:US
Mailing Address - Phone:608-627-1810
Mailing Address - Fax:608-627-1815
Practice Address - Street 1:213 N TURNER
Practice Address - Street 2:
Practice Address - City:VIOLA
Practice Address - State:WI
Practice Address - Zip Code:54664
Practice Address - Country:US
Practice Address - Phone:608-627-1810
Practice Address - Fax:608-627-1815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60-01171341600000X
WI3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41348900Medicaid
000082320Medicare ID - Type Unspecified