Healthcare Provider Details

I. General information

NPI: 1548217912
Provider Name (Legal Business Name): OCOOCH MOUNTAIN RESCUE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ROYAL AVE.
GAYS MILLS WI
54631-0000
US

IV. Provider business mailing address

PO BOX 204
GAYS MILLS WI
54631-0204
US

V. Phone/Fax

Practice location:
  • Phone: 608-735-4698
  • Fax: 608-735-4040
Mailing address:
  • Phone: 608-735-4698
  • Fax: 608-735-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number6600149
License Number StateWI

VIII. Authorized Official

Name: TRESA MCCARN
Title or Position: TREASURER
Credential: EMT B
Phone: 608-735-4698