Provider Demographics
NPI:1558312124
Name:TOWN OF BOULDER JUNCTION
Entity type:Organization
Organization Name:TOWN OF BOULDER JUNCTION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-385-2002
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:BOULDER JUNCTION
Mailing Address - State:WI
Mailing Address - Zip Code:54512-0395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5386 PARK ST
Practice Address - Street 2:
Practice Address - City:BOULDER JUNCTION
Practice Address - State:WI
Practice Address - Zip Code:54512-9605
Practice Address - Country:US
Practice Address - Phone:715-385-2002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
006532OtherHEALTH ALLIANCE
1012338OtherPHYSICIAN'S PLUS
WI0101OtherJOHN DEERE
WI41335600Medicaid
=========012OtherVALLEY HEALTH PLAN
WI0101OtherJOHN DEERE