MEDICARE: WHITE LAKE AMBULANCE SERVICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance	611002	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225033855
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE LAKE AMBULANCE SERVICE

Provider Business Mailing Address
First Line	:	5085 WILCOX ST
Second Line	:
City	:	MONTAGUE
State	:	MI
Zip	:	49437-1558
Country	:	US
Telephone Number	:	231-894-4306
Fax Number	:	231-893-0249

Provider Business Practice Location Address
First Line	:	5085 WILCOX ST
Second Line	:
City	:	MONTAGUE
State	:	MI
Zip	:	49437-1558
Country	:	US
Telephone Number	:	231-894-4306
Fax Number	:	231-893-0249

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. JONATHON DEGEN
Credential	:
Telephone Number	:	231-894-4306

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	06/29/2016

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Directions to “WHITE LAKE AMBULANCE SERVICE ” Practice Location

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