Provider Demographics
NPI:1538281167
Name:TRI-STATE REGIONAL AMBULANCE, INC.
Entity Type:Organization
Organization Name:TRI-STATE REGIONAL AMBULANCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:TORNSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-782-2282
Mailing Address - Street 1:235 CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-3119
Mailing Address - Country:US
Mailing Address - Phone:608-519-3345
Mailing Address - Fax:608-782-4452
Practice Address - Street 1:122 S ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-1638
Practice Address - Country:US
Practice Address - Phone:608-782-2282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
341600000X
WI343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41476300Medicaid