Provider Demographics
NPI:1659560449
Name:CORNELL AREA AMBULANCE SERVICE
Entity Type:Organization
Organization Name:CORNELL AREA AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-828-1258
Mailing Address - Street 1:26344 240TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLCOMBE
Mailing Address - State:WI
Mailing Address - Zip Code:54745-5706
Mailing Address - Country:US
Mailing Address - Phone:715-838-8898
Mailing Address - Fax:715-838-8895
Practice Address - Street 1:412 S 3RD ST
Practice Address - Street 2:
Practice Address - City:CORNELL
Practice Address - State:WI
Practice Address - Zip Code:54732-8303
Practice Address - Country:US
Practice Address - Phone:715-838-8898
Practice Address - Fax:715-838-8895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41324900Medicaid