Provider Demographics
NPI:1871176560
Name:COUNTY OF GREEN LAKE
Entity type:Organization
Organization Name:COUNTY OF GREEN LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:N
Authorized Official - Last Name:JEROME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-294-4070
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-0069
Mailing Address - Country:US
Mailing Address - Phone:920-361-3484
Mailing Address - Fax:920-361-1195
Practice Address - Street 1:222 LEFFERT ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-2166
Practice Address - Country:US
Practice Address - Phone:920-361-3484
Practice Address - Fax:920-361-1195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)