Provider Demographics
NPI:1174629075
Name:HOLY FAMILY MEMORIAL INC
Entity Type:Organization
Organization Name:HOLY FAMILY MEMORIAL INC
Other - Org Name:FROEDTERT HOLY FAMILY MEMORIAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:VEESER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:920-320-2730
Mailing Address - Street 1:N74W12501 LEATHERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-4490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-3712
Practice Address - Country:US
Practice Address - Phone:920-320-8436
Practice Address - Fax:920-320-8443
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLY FAMILY MEMORIAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-16
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI143251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41536200Medicaid
WI100165952Medicaid
WI41536200Medicaid
WI=========047OtherBLUE CROSS BLUE SHIELD