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General NPI Number Information
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NPI Number | 1225033855
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Entity Type | Organization
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Legal Business Name | WHITE LAKE AMBULANCE SERVICE
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Dates
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Enumeration Date | 06/20/2005
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Last Update Date | 06/29/2016
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Provider Practice Location Address
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Address Line | 5085 WILCOX ST
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City | MONTAGUE
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State | MI
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Zip | 49437-1558
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Country | US
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Telephone | 231-894-4306
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Fax | 231-893-0249
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Provider Business Mailing Address
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Address Line | 5085 WILCOX ST
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City | MONTAGUE
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State | MI
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Zip | 49437-1558
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Country | US
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Telephone | 231-894-4306
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Fax | 231-893-0249
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. JONATHON DEGEN
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Credential |
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Telephone | 231-894-4306
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3416L0300X
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Taxonomy Name | Land Ambulance
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License Number | 611002
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License Number State | MI
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