MEDICARE: LAUDERDALE LAGRANGE FIRE DEPARTMENT INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance	60-00522	WI

General Provider Information

NPI Number	:	1114924206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAUDERDALE LAGRANGE FIRE DEPARTMENT INC

Provider Business Mailing Address
First Line	:	W6080 US HIGHWAY 12
Second Line	:
City	:	WHITEWATER
State	:	WI
Zip	:	53190-4033
Country	:	US
Telephone Number	:	262-495-4658
Fax Number	:	262-495-4686

Provider Business Practice Location Address
First Line	:	W6080 US HIGHWAY 12
Second Line	:
City	:	WHITEWATER
State	:	WI
Zip	:	53190-4033
Country	:	US
Telephone Number	:	262-495-8400
Fax Number	:	262-495-8426

Authorized Official
Title or Position	:	EMS CAPTAIN
Name	:	BEN CLARK
Credential	:
Telephone Number	:	262-949-9704

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	03/30/2026

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