Basic Information
| Provider Information | |||||||||
| NPI: | 1699438754 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLY FAMILY LLC. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 49650 LAKEBRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SHELBY TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483153511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867377144 | ||||||||
| FaxNumber: | 5867823847 | ||||||||
| Practice Location | |||||||||
| Address1: | 2850 PARENT AVE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480922472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865789526 | ||||||||
| FaxNumber: | 5867823847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2021 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | MANIMALETHU | ||||||||
| AuthorizedOfficialFirstName: | TINO | ||||||||
| AuthorizedOfficialMiddleName: | RAJU | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5865789526 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PTA. | ||||||||
| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253J00000X | Y | Agencies | Foster Care Agency |
No ID Information.