=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174668495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREMONT- WOLF RIVER EMS,LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | E7405 HIGHWAY 110
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-446-2288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 393
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54940-0393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY-TREASURER
-----------------------------------------------------
Name | MR. PHILIP LEWIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-446-2288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 6001168
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------