Healthcare Provider Details

I. General information

NPI: 1477958510
Provider Name (Legal Business Name): HOLIDAY HOUSE OF MANITOWOC COUNTY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2014
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2818 MEADOW LN
MANITOWOC WI
54220-3739
US

IV. Provider business mailing address

PO BOX 579
MANITOWOC WI
54221-0579
US

V. Phone/Fax

Practice location:
  • Phone: 920-682-4663
  • Fax: 920-682-1091
Mailing address:
  • Phone: 920-682-4663
  • Fax: 920-682-1091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: THOMAS E KEIL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 920-682-4663