Provider Demographics
NPI:1356058713
Name:CITY OF LAKE MILLS
Entity type:Organization
Organization Name:CITY OF LAKE MILLS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAPTAIN
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:THEDER
Authorized Official - Suffix:
Authorized Official - Credentials:AEMT
Authorized Official - Phone:920-648-5117
Mailing Address - Street 1:200D WATER ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1632
Mailing Address - Country:US
Mailing Address - Phone:920-648-5117
Mailing Address - Fax:920-648-8743
Practice Address - Street 1:120 VETERANS LN
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-1555
Practice Address - Country:US
Practice Address - Phone:920-648-5117
Practice Address - Fax:920-648-8743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-03
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6600034OtherSERVICE LICENSE NUMBER