=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891801015
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TESS CORNERS VOLUNTEER FIRE DEPT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 04/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | W144S6731 TESS CORNERS DR
-----------------------------------------------------
City | MUSKEGO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53150-3155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-422-9733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 72140
-----------------------------------------------------
City | CEDARBURG
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53012-7340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-375-9610
-----------------------------------------------------
Fax | 262-375-9608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MICHELLE SCHERFF SULIK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-375-9610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 6000516
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------