Provider Demographics
NPI:1659636108
Name:ST NICHOLAS HOSPITAL-SISTERS OF THIRD ORDER OF ST FRANCIS
Entity Type:Organization
Organization Name:ST NICHOLAS HOSPITAL-SISTERS OF THIRD ORDER OF ST FRANCIS
Other - Org Name:PREVEA HEALTH-PLYMOUTH DME SUPPLIER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-496-4700
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:825 WALTON DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-5022
Practice Address - Country:US
Practice Address - Phone:920-892-4322
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:2012-07-11
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI00235Medicare PIN