Provider Demographics
NPI:1700830973
Name:VILLAGE NORTH FOND DU LAC
Entity Type:Organization
Organization Name:VILLAGE NORTH FOND DU LAC
Other - Org Name:NORTH FOND DU LAC EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:HORNUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-929-3954
Mailing Address - Street 1:16 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-1387
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:NORTH FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-1387
Practice Address - Country:US
Practice Address - Phone:920-929-3954
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
1022683OtherPHYSICIAN'S PLUS
WI41327400Medicaid
000082921OtherADVOCARE
1962OtherNETWORK HEALTH PLAN
WI0101OtherJOHN DEERE
1022683OtherPHYSICIAN'S PLUS
=========011OtherVALLEY HEALTH PLAN
WI41327400Medicaid
000082921Medicare ID - Type UnspecifiedMEDICARE