Healthcare Provider Details

I. General information

NPI: 1114923935
Provider Name (Legal Business Name): CLEMENT MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 S 92ND ST
GREENFIELD WI
53228-2140
US

IV. Provider business mailing address

3939 S 92ND ST
GREENFIELD WI
53228-2140
US

V. Phone/Fax

Practice location:
  • Phone: 414-321-1800
  • Fax: 414-546-7357
Mailing address:
  • Phone: 414-321-1800
  • Fax: 414-546-7357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2724
License Number StateWI

VIII. Authorized Official

Name: DENNIS FERGER
Title or Position: ADMINISTRATOR
Credential:
Phone: 414-546-7330