Provider Demographics
NPI:1336214493
Name:CIVIL CITY OF LAKE STATION IND
Entity Type:Organization
Organization Name:CIVIL CITY OF LAKE STATION IND
Other - Org Name:CITY OF LAKE STATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:FAZEKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-945-6629
Mailing Address - Street 1:1969 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE STATION
Mailing Address - State:IN
Mailing Address - Zip Code:46405-2059
Mailing Address - Country:US
Mailing Address - Phone:219-962-2081
Mailing Address - Fax:
Practice Address - Street 1:1876 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:LAKE STATION
Practice Address - State:IN
Practice Address - Zip Code:46405
Practice Address - Country:US
Practice Address - Phone:219-962-8295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02913416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000215119OtherANTHEM
IN200262890AMedicaid
IN000000215119OtherANTHEM