MEDICARE: PINE CREEK TRANSPORTATION SERVICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174723043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE CREEK TRANSPORTATION SERVICE LLC

Provider Business Mailing Address
First Line	:	N7260 S DAVIS RD
Second Line	:
City	:	TAYLOR
State	:	WI
Zip	:	54659-8309
Country	:	US
Telephone Number	:	715-662-2028
Fax Number	:	715-662-3022

Provider Business Practice Location Address
First Line	:	N7260 S DAVIS RD
Second Line	:
City	:	TAYLOR
State	:	WI
Zip	:	54659-8309
Country	:	US
Telephone Number	:	715-662-2028
Fax Number	:	715-662-3022

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DAVID ALLEN BURNELL I
Credential	:
Telephone Number	:	715-662-2028

Provider Enumeration Date	:	07/19/2007
Last Update Date	:	07/19/2007

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