Provider Demographics
NPI:1174723043
Name:PINE CREEK TRANSPORTATION SERVICE LLC
Entity type:Organization
Organization Name:PINE CREEK TRANSPORTATION SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BURNELL
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:715-662-2028
Mailing Address - Street 1:N7260 S DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:WI
Mailing Address - Zip Code:54659-8309
Mailing Address - Country:US
Mailing Address - Phone:715-662-2028
Mailing Address - Fax:715-662-3022
Practice Address - Street 1:N7260 S DAVIS RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:WI
Practice Address - Zip Code:54659-8309
Practice Address - Country:US
Practice Address - Phone:715-662-2028
Practice Address - Fax:715-662-3022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41490900Medicaid