Healthcare Provider Details

I. General information

NPI: 1225033855
Provider Name (Legal Business Name): WHITE LAKE AMBULANCE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5085 WILCOX ST
MONTAGUE MI
49437-1558
US

IV. Provider business mailing address

5085 WILCOX ST
MONTAGUE MI
49437-1558
US

V. Phone/Fax

Practice location:
  • Phone: 231-894-4306
  • Fax: 231-893-0249
Mailing address:
  • Phone: 231-894-4306
  • Fax: 231-893-0249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number611002
License Number StateMI

VIII. Authorized Official

Name: MR. JONATHON DEGEN
Title or Position: DIRECTOR
Credential:
Phone: 231-894-4306