Healthcare Provider Details

I. General information

NPI: 1194639435
Provider Name (Legal Business Name): RANDOM LAKE FIRE DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 N SPRING ST
RANDOM LAKE WI
53075-1726
US

IV. Provider business mailing address

718 N SPRING ST
RANDOM LAKE WI
53075-1726
US

V. Phone/Fax

Practice location:
  • Phone: 920-994-9817
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. BLAINE WERNER
Title or Position: EMS DIRECTOR
Credential:
Phone: 920-994-4817