Provider Demographics
NPI:1780632497
Name:STONE BANK VOLUNTEER FIRE
Entity Type:Organization
Organization Name:STONE BANK VOLUNTEER FIRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:KLOKOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-966-2414
Mailing Address - Street 1:PO BOX 72140
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-7340
Mailing Address - Country:US
Mailing Address - Phone:262-375-9610
Mailing Address - Fax:262-375-9608
Practice Address - Street 1:W335N7107 STONEBANK RD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-1407
Practice Address - Country:US
Practice Address - Phone:262-966-2414
Practice Address - Fax:262-966-2831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60012113416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41359600Medicaid
WI41359600Medicaid
WI000081159Medicare ID - Type Unspecified