Provider Demographics
NPI:1194852061
Name:VILLAGE OF VALDERS
Entity type:Organization
Organization Name:VILLAGE OF VALDERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SERVICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-775-4526
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:103 EISENHOWER STREET
Mailing Address - City:VALDERS
Mailing Address - State:WI
Mailing Address - Zip Code:54245-0307
Mailing Address - Country:US
Mailing Address - Phone:920-775-4526
Mailing Address - Fax:920-775-9782
Practice Address - Street 1:103 EISENHOWER STREET
Practice Address - Street 2:
Practice Address - City:VALDERS
Practice Address - State:WI
Practice Address - Zip Code:54245
Practice Address - Country:US
Practice Address - Phone:920-775-4526
Practice Address - Fax:920-775-9782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60004693416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41338400Medicaid
WI41338400Medicaid