Provider Demographics
NPI:1568622074
Name:NORTHEAST WISCONSIN TRANSPORTATION SERVICES INC
Entity Type:Organization
Organization Name:NORTHEAST WISCONSIN TRANSPORTATION SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LACROSSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-825-7411
Mailing Address - Street 1:214 CLOVER AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-4609
Mailing Address - Country:US
Mailing Address - Phone:920-825-7411
Mailing Address - Fax:
Practice Address - Street 1:9431 COUNTY ROAD D
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:WI
Practice Address - Zip Code:54213
Practice Address - Country:US
Practice Address - Phone:920-825-7411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41440500343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41440500Medicaid