Provider Demographics
NPI:1629176649
Name:PARDEEVILLE DISTRICT AMBULANCE SERVICE
Entity Type:Organization
Organization Name:PARDEEVILLE DISTRICT AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:HENNING
Authorized Official - Suffix:
Authorized Official - Credentials:AEMT
Authorized Official - Phone:608-429-9089
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:
Mailing Address - City:PARDEEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53954-0396
Mailing Address - Country:US
Mailing Address - Phone:608-429-9089
Mailing Address - Fax:
Practice Address - Street 1:501 GILLETTE ST
Practice Address - Street 2:
Practice Address - City:PARDEEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53954
Practice Address - Country:US
Practice Address - Phone:608-429-9089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001377341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41356600Medicaid