Provider Demographics
NPI:1568475895
Name:VILLAGE OF LISBON
Entity type:Organization
Organization Name:VILLAGE OF LISBON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKOLAUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-246-6100
Mailing Address - Street 1:W234 N8676 WOODSIDE ROAD
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-1545
Mailing Address - Country:US
Mailing Address - Phone:262-246-6100
Mailing Address - Fax:262-820-2023
Practice Address - Street 1:N72 W24958 GOOD HOPE ROAD
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089
Practice Address - Country:US
Practice Address - Phone:262-538-3902
Practice Address - Fax:262-820-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60012613416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41315400Medicaid
=========OtherEIN US GOVT
000080028Medicare ID - Type Unspecified