Provider Demographics
NPI:1609933001
Name:JOHNSON CREEK FIRE EMS DEPT.
Entity Type:Organization
Organization Name:JOHNSON CREEK FIRE EMS DEPT.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VILLAGE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MODERACKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-699-2296
Mailing Address - Street 1:125 DEPOT ST.
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53038-0451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 DEPOT ST.
Practice Address - Street 2:
Practice Address - City:JOHNSON CREEK
Practice Address - State:WI
Practice Address - Zip Code:53038-0451
Practice Address - Country:US
Practice Address - Phone:920-699-2296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60011803416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41307600Medicaid