Healthcare Provider Details

I. General information

NPI: 1336314632
Provider Name (Legal Business Name): HOLY FAMILY MEMORIAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 WESTERN AVE
MANITOWOC WI
54220-3712
US

IV. Provider business mailing address

N74W12501 LEATHERWOOD CT
MENOMONEE FALLS WI
53051-4490
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier100163450
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer
# 2
Identifier32946000
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name: ALICIA MAITLAND
Title or Position: SVP /FH FINANCE
Credential:
Phone: 414-777-0979