Provider Demographics
NPI:1609991389
Name:CITY OF CALEDONIA
Entity Type:Organization
Organization Name:CITY OF CALEDONIA
Other - Org Name:CALEDONIA AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AMBULANCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:TORNSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-450-3201
Mailing Address - Street 1:231 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55921-1396
Mailing Address - Country:US
Mailing Address - Phone:507-725-3450
Mailing Address - Fax:
Practice Address - Street 1:231 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MN
Practice Address - Zip Code:55921-1396
Practice Address - Country:US
Practice Address - Phone:507-725-3297
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00413416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN39880CAOtherBLUE CROSS BLUE SHIELD
WI80961900Medicaid