=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124695069
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERGENCY RESCUE SQUAD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2021
-----------------------------------------------------
Last Update Date | 07/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2710 WOLESKE RD
-----------------------------------------------------
City | MARINETTE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54143-3844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-735-3261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 547
-----------------------------------------------------
City | MARINETTE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54143-0547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-735-3261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AMBULANCE MANAGER
-----------------------------------------------------
Name | GREGORY LOLL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-735-3261
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------