Basic Information
| Provider Information | |||||||||
| NPI: | 1407031248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOLY FAMILY MEMORIAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | N74W12501 LEATHERWOOD CT | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530514490 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542203712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203202011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2007 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4147770373 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DBA HOLY FAMILY MEMORIAL - CRNAS | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 32795700 | 05 | WI | MEDICAID | 100161619 | 05 | WI | MEDICAID |