Basic Information
| Provider Information | |||||||||
| NPI: | 1568559490 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLY FAMILY MEMORIAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOLY FAMILY MEMORIAL CHIROPRACTIC / LAKESHORE PODIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2209 | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542212290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203202840 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1650 S 41ST ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542207316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203204700 | ||||||||
| FaxNumber: | 9206842094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 09/13/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAUBER | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR HEALTH INFORMATION MANAGEM | ||||||||
| AuthorizedOfficialTelephone: | 9203203444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOLY FAMILY MEMORIAL INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 918 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 111N00000X | 2710 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 38736800 | 05 | WI | MEDICAID |