Provider Demographics
NPI:1962425090
Name:TOWN OF CEDAR LAKE
Entity type:Organization
Organization Name:TOWN OF CEDAR LAKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKENING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-374-5961
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:7408 CONSTITUTION AVENUE
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-0707
Mailing Address - Country:US
Mailing Address - Phone:219-374-7000
Mailing Address - Fax:219-374-4446
Practice Address - Street 1:9430 W. 133RD AVENUE
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-0459
Practice Address - Country:US
Practice Address - Phone:219-374-5961
Practice Address - Fax:219-374-5999
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOWN OF CEDAR LAKE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-26
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3416L0300X, 146N00000X
IN146M00000X, 146N00000X
IN0245146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, ParamedicGroup - Multi-Specialty
Yes3416L0300XTransportation ServicesAmbulanceLand TransportGroup - Multi-Specialty
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, IntermediateGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100281690AMedicaid
IN978580OtherMEDICARE
IN978580OtherMEDICARE