Healthcare Provider Details

I. General information

NPI: 1396041448
Provider Name (Legal Business Name): VILLAGE OF KEWASKUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 FOND DU LAC AVE
KEWASKUM WI
53040-9492
US

IV. Provider business mailing address

PO BOX 72140
CEDARBURG WI
53012-7340
US

V. Phone/Fax

Practice location:
  • Phone: 262-626-2411
  • Fax: 262-626-3635
Mailing address:
  • Phone: 262-375-9610
  • Fax: 262-375-9608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number6000375
License Number StateWI

VIII. Authorized Official

Name: MICHELLE L SCHERFF SULIK
Title or Position: VICE PRESIDENT
Credential:
Phone: 262-375-9610