Provider Demographics
NPI:1609882448
Name:ST. MARY'S HOME FOR THE AGED, INC
Entity Type:Organization
Organization Name:ST. MARY'S HOME FOR THE AGED, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDNET/CEO/NHA/MSN
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLTYS
Authorized Official - Suffix:
Authorized Official - Credentials:NHA, MSN
Authorized Official - Phone:920-684-7171
Mailing Address - Street 1:1635 S 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-5652
Mailing Address - Country:US
Mailing Address - Phone:920-684-7171
Mailing Address - Fax:920-684-0118
Practice Address - Street 1:1635 S 21ST ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-6380
Practice Address - Country:US
Practice Address - Phone:920-684-7171
Practice Address - Fax:920-684-0118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI540314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20136700Medicaid
WI=========015OtherBCBS
WI=========015OtherBCBS