Healthcare Provider Details

I. General information

NPI: 1609933001
Provider Name (Legal Business Name): JOHNSON CREEK FIRE EMS DEPT.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 DEPOT ST.
JOHNSON CREEK WI
53038-0451
US

IV. Provider business mailing address

125 DEPOT ST.
JOHNSON CREEK WI
53038-0451
US

V. Phone/Fax

Practice location:
  • Phone: 920-699-2296
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number6001180
License Number StateWI

VIII. Authorized Official

Name: PAUL MODERACKI
Title or Position: VILLAGE ADMINISTRATOR
Credential:
Phone: 920-699-2296