Provider Demographics
NPI:1558428177
Name:CITY OF EAST JORDAN
Entity Type:Organization
Organization Name:CITY OF EAST JORDAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:PARAMEDIC IC AAS
Authorized Official - Phone:231-536-7881
Mailing Address - Street 1:201 MAIN STREET
Mailing Address - Street 2:PO BOX 499
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727
Mailing Address - Country:US
Mailing Address - Phone:231-536-7881
Mailing Address - Fax:231-536-2785
Practice Address - Street 1:201 MAIN STREET
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727
Practice Address - Country:US
Practice Address - Phone:231-536-7881
Practice Address - Fax:231-536-2785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1510033416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3001914Medicaid
MI3001914Medicaid