Provider Demographics
NPI:1972845337
Name:GREAT LAKES EMS INC.
Entity Type:Organization
Organization Name:GREAT LAKES EMS INC.
Other - Org Name:ACTION SPORTS EMS
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MC CLINTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:NREMT
Authorized Official - Phone:715-889-4491
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:BRILLION
Mailing Address - State:WI
Mailing Address - Zip Code:54110-0033
Mailing Address - Country:US
Mailing Address - Phone:715-889-4491
Mailing Address - Fax:
Practice Address - Street 1:W521 HACKER ROAD
Practice Address - Street 2:410
Practice Address - City:BRILLION
Practice Address - State:WI
Practice Address - Zip Code:54110-4136
Practice Address - Country:US
Practice Address - Phone:715-889-4491
Practice Address - Fax:855-425-3066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-25
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66049353416L0300X
IL03 30993416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport