Provider Demographics
NPI:1235235474
Name:HOLY FAMILY MEMORIAL INC
Entity Type:Organization
Organization Name:HOLY FAMILY MEMORIAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-320-3481
Mailing Address - Street 1:2300 WESTERN AVE
Mailing Address - Street 2:PO BOX 2170
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-3712
Mailing Address - Country:US
Mailing Address - Phone:920-320-3486
Mailing Address - Fax:920-320-3500
Practice Address - Street 1:333 REED AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2087
Practice Address - Country:US
Practice Address - Phone:920-320-8410
Practice Address - Fax:920-320-8414
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLY FAMILY MEMORIAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-15
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI080000002OtherWEA
WI11014600Medicaid
WI11014600Medicaid
WI11014600Medicaid