Healthcare Provider Details

I. General information

NPI: 1700830973
Provider Name (Legal Business Name): VILLAGE NORTH FOND DU LAC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 GARFIELD ST
NORTH FOND DU LAC WI
54937-1387
US

IV. Provider business mailing address

16 GARFIELD ST
NORTH FOND DU LAC WI
54937-1387
US

V. Phone/Fax

Practice location:
  • Phone: 920-929-3954
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: CHUCK HORNUNG
Title or Position: CHIEF
Credential:
Phone: 920-929-3954