Provider Demographics
NPI:1124115613
Name:TOWN OF BOURBON
Entity type:Organization
Organization Name:TOWN OF BOURBON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLERK-TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-342-4755
Mailing Address - Street 1:PO BOX 2122
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-1122
Mailing Address - Country:US
Mailing Address - Phone:574-342-4755
Mailing Address - Fax:574-342-3205
Practice Address - Street 1:104 E PARK AVE
Practice Address - Street 2:
Practice Address - City:BOURBON
Practice Address - State:IN
Practice Address - Zip Code:46504-1528
Practice Address - Country:US
Practice Address - Phone:574-342-4755
Practice Address - Fax:574-342-3205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN979860Medicare ID - Type Unspecified