Provider Demographics
NPI:1063400414
Name:WILLINGTON FIRE DEPT #1
Entity type:Organization
Organization Name:WILLINGTON FIRE DEPT #1
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AMBULANCE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:GANTICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-429-0288
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:W SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06093
Mailing Address - Country:US
Mailing Address - Phone:860-668-3885
Mailing Address - Fax:860-668-3885
Practice Address - Street 1:426 RIVER RD
Practice Address - Street 2:
Practice Address - City:WILLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06279-1310
Practice Address - Country:US
Practice Address - Phone:860-429-0288
Practice Address - Fax:860-487-4545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC160B13416L0300X, 341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
590009415OtherRAILROAD MEDICARE
CT710C160B1CT01OtherANTHEM BLUE CROSS BLUE SH
CT004119857Medicaid
5300009415OtherRAILROAD MEDICARE
756028OtherCONNECTICARE
590009415OtherRAILROAD MEDICARE