Provider Demographics
NPI:1760425375
Name:VILLAGE OF FONTANA-ON-GENEVA LAKE
Entity Type:Organization
Organization Name:VILLAGE OF FONTANA-ON-GENEVA LAKE
Other - Org Name:FONTANA FIRE/RESCUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-275-6136
Mailing Address - Street 1:POST OFFICE BOX 200
Mailing Address - Street 2:175 VALLEY VIEW DRIVE
Mailing Address - City:FONTANA
Mailing Address - State:WI
Mailing Address - Zip Code:53125-1192
Mailing Address - Country:US
Mailing Address - Phone:262-275-6136
Mailing Address - Fax:262-275-8088
Practice Address - Street 1:190 FONTANA BOULEVARD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:WI
Practice Address - Zip Code:53125-1000
Practice Address - Country:US
Practice Address - Phone:262-275-2131
Practice Address - Fax:262-275-2257
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VILLAGE OF FONTANA-ON-GENEVA LAKE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60001373416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41355400OtherH.I.R.S.P.
WI41355400OtherWISCONSIN RENAL PROGRAM
WI41355400Medicaid
WI41355400OtherWISCONSIN RENAL PROGRAM
WI41355400OtherWISCONSIN RENAL PROGRAM