Provider Demographics
NPI:1639106156
Name:JACKSON TWP EMERGENCY AMBULANCE SERVICE, INC.
Entity Type:Organization
Organization Name:JACKSON TWP EMERGENCY AMBULANCE SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRONI
Authorized Official - Suffix:
Authorized Official - Credentials:BASIC EMT
Authorized Official - Phone:574-831-4431
Mailing Address - Street 1:PO BOX 2122
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-1122
Mailing Address - Country:US
Mailing Address - Phone:734-479-6300
Mailing Address - Fax:734-479-6319
Practice Address - Street 1:19153 COUNTY ROAD 146
Practice Address - Street 2:
Practice Address - City:NEW PARIS
Practice Address - State:IN
Practice Address - Zip Code:46553-9100
Practice Address - Country:US
Practice Address - Phone:574-831-4431
Practice Address - Fax:574-831-4431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01363416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN977910Medicare PIN