Healthcare Provider Details

I. General information

NPI: 1871176560
Provider Name (Legal Business Name): COUNTY OF GREEN LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2021
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 LEFFERT ST
BERLIN WI
54923-2166
US

IV. Provider business mailing address

PO BOX 69
BERLIN WI
54923-0069
US

V. Phone/Fax

Practice location:
  • Phone: 920-361-3484
  • Fax: 920-361-1195
Mailing address:
  • Phone: 920-361-3484
  • Fax: 920-361-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: JASON N JEROME
Title or Position: DIRECTOR
Credential:
Phone: 920-294-4070