Basic Information
| Provider Information | |||||||||
| NPI: | 1386638039 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF DELAFIELD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 INDUSTRIAL LOOP | ||||||||
| Address2: | |||||||||
| City: | GREENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531292452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144234100 | ||||||||
| FaxNumber: | 4144234134 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | DELAFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530181817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626466235 | ||||||||
| FaxNumber: | 2626466236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FRANCIS | ||||||||
| AuthorizedOfficialFirstName: | BALFORD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CPC | ||||||||
| AuthorizedOfficialTelephone: | 4144234100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 6001158 | WI | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 41339000 | 05 | WI | MEDICAID |