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General NPI Number Information
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NPI Number | 1972845337
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Entity Type | Organization
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Legal Business Name | GREAT LAKES EMS INC.
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Dates
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Enumeration Date | 03/25/2013
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Last Update Date | 02/08/2021
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Provider Practice Location Address
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Address Line | W521 HACKER ROAD 410
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City | BRILLION
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State | WI
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Zip | 54110-4136
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Country | US
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Telephone | 715-889-4491
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Fax | 855-425-3066
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Provider Business Mailing Address
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Address Line | PO BOX 33
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City | BRILLION
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State | WI
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Zip | 54110-0033
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Country | US
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Telephone | 715-889-4491
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. RYAN C MC CLINTOCK
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Credential | NREMT
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Telephone | 715-889-4491
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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 | 6604935
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 3416L0300X
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Taxonomy Name | Land Ambulance
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License Number | 03 3099
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License Number State | IL
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