Provider Demographics
NPI:1528172905
Name:VILLAGE OF JOHNSON CREEK
Entity type:Organization
Organization Name:VILLAGE OF JOHNSON CREEK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FIRE CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-699-3456
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:120 SOUTH WATERTOWN STREET
Mailing Address - City:JOHNSON CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53038-0529
Mailing Address - Country:US
Mailing Address - Phone:920-699-3456
Mailing Address - Fax:920-699-3458
Practice Address - Street 1:120 S WATERTOWN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CREEK
Practice Address - State:WI
Practice Address - Zip Code:53038-9510
Practice Address - Country:US
Practice Address - Phone:920-699-5258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41307600Medicaid
WI519077OtherCOMMERCIAL
WI519077OtherCOMMERCIAL