Healthcare Provider Details

I. General information

NPI: 1205186632
Provider Name (Legal Business Name): INTEGRATED FIRST RESPONSE-GREAT LAKES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 WOODWARD AVE
KINGSFORD MI
49802
US

IV. Provider business mailing address

PO BOX 512
BRANDON SD
57005-0512
US

V. Phone/Fax

Practice location:
  • Phone: 855-437-9114
  • Fax:
Mailing address:
  • Phone: 605-582-6096
  • Fax: 605-582-8983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416A0800X
TaxonomyAir Ambulance
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: DOUG DAVID ANDERSON
Title or Position: TREASURER
Credential:
Phone: 605-366-3299