Healthcare Provider Details

I. General information

NPI: 1336214493
Provider Name (Legal Business Name): CIVIL CITY OF LAKE STATION IND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1876 FAIRVIEW AVE
LAKE STATION IN
46405
US

IV. Provider business mailing address

1969 CENTRAL AVE
LAKE STATION IN
46405-2059
US

V. Phone/Fax

Practice location:
  • Phone: 219-962-8295
  • Fax:
Mailing address:
  • Phone: 219-962-2081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number0291
License Number StateIN

VIII. Authorized Official

Name: CHARLES FAZEKAS
Title or Position: FIRE CHIEF
Credential:
Phone: 219-945-6629