Provider Demographics
NPI:1659611077
Name:ST NICHOLAS HOSPITAL-SISTERS OF THE THIRD ORDER OF ST FRANCIS
Entity Type:Organization
Organization Name:ST NICHOLAS HOSPITAL-SISTERS OF THE THIRD ORDER OF ST FRANCIS
Other - Org Name:PREVEA HEALTH CLINIC LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAGNALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-496-4700
Mailing Address - Street 1:3100 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1948
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:3100 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1948
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST NICHOLAS HOSPITAL OF THE HOSPITAL SISTERS OF ST FRANCIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-21
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI52D0388757OtherCLIA