Provider Demographics
NPI:1609849041
Name:LAKESIDE VOLUNTEER FIRE DEPARTMENT
Entity Type:Organization
Organization Name:LAKESIDE VOLUNTEER FIRE DEPARTMENT
Other - Org Name:LAKESIDE FIRE DISTRICT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAN SCOTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-368-6112
Mailing Address - Street 1:PO BOX 1109
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-1109
Mailing Address - Country:US
Mailing Address - Phone:928-368-6112
Mailing Address - Fax:928-368-5643
Practice Address - Street 1:2922 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-0000
Practice Address - Country:US
Practice Address - Phone:928-368-6112
Practice Address - Fax:928-368-6543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZCON111341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0151440OtherBLUE CROSS
AZ152843Medicaid
AZRFBKMMedicare ID - Type Unspecified
AZ590007944Medicare ID - Type UnspecifiedRAILROAD