Provider Demographics
NPI:1912196700
Name:CITY OF BLOOMER
Entity Type:Organization
Organization Name:CITY OF BLOOMER
Other - Org Name:BLOOMER COMMUNITY AMBULANCE SVC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICI
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOBRAATEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-838-8898
Mailing Address - Street 1:1200 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMER
Mailing Address - State:WI
Mailing Address - Zip Code:54724-1613
Mailing Address - Country:US
Mailing Address - Phone:715-838-8898
Mailing Address - Fax:715-838-8895
Practice Address - Street 1:1200 15TH AVE
Practice Address - Street 2:
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724-1613
Practice Address - Country:US
Practice Address - Phone:715-838-8898
Practice Address - Fax:715-838-8895
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF BLOOMER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-17
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41339300Medicaid
WI000085700Medicare PIN