Healthcare Provider Details

I. General information

NPI: 1104804657
Provider Name (Legal Business Name): THERESA AMBULANCE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 DEPOT ROAD
THERESA WI
53091
US

IV. Provider business mailing address

PO BOX 275
THERESA WI
53091-0275
US

V. Phone/Fax

Practice location:
  • Phone: 920-488-6301
  • Fax: 920-488-6301
Mailing address:
  • Phone: 920-488-6301
  • Fax: 920-488-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number6000326
License Number StateWI

VIII. Authorized Official

Name: MR. KEVIN LESTER BAERWALD
Title or Position: OPERATION MANAGER
Credential: EMT
Phone: 920-488-6301