Provider Demographics
NPI:1801831375
Name:ONTWA JEFFERSON MASON MILTON CALVIN TNSHPS & VILLAGE OF EDWARDSBURG
Entity Type:Organization
Organization Name:ONTWA JEFFERSON MASON MILTON CALVIN TNSHPS & VILLAGE OF EDWARDSBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIELMAIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-663-2347
Mailing Address - Street 1:26273 E SHORE DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-8453
Mailing Address - Country:US
Mailing Address - Phone:269-663-2347
Mailing Address - Fax:269-663-0072
Practice Address - Street 1:26273 E SHORE DR
Practice Address - Street 2:
Practice Address - City:EDWARDSBURG
Practice Address - State:MI
Practice Address - Zip Code:49112-8453
Practice Address - Country:US
Practice Address - Phone:269-663-2347
Practice Address - Fax:269-663-0072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI141003341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3001530Medicaid
MI3001530Medicaid