Provider Demographics
NPI:1528011657
Name:VILLAGE OF CLEAR LAKE
Entity Type:Organization
Organization Name:VILLAGE OF CLEAR LAKE
Other - Org Name:CLEAR LAKE AREA AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-263-2804
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54005-0215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:457 3RD AVE
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:WI
Practice Address - Zip Code:54005-8905
Practice Address - Country:US
Practice Address - Phone:715-263-2804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41328500OtherHIRSP
8182723OtherMEDICA
WI41328500Medicaid
=========010OtherBCBS
8182723OtherMEDICA