Healthcare Provider Details

I. General information

NPI: 1154303287
Provider Name (Legal Business Name): JIM ENLUND N.H.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 S 84TH ST
MILWAUKEE WI
53227-3703
US

IV. Provider business mailing address

3023 S 84TH ST
MILWAUKEE WI
53227-3703
US

V. Phone/Fax

Practice location:
  • Phone: 414-607-4362
  • Fax: 414-607-4502
Mailing address:
  • Phone: 414-607-4362
  • Fax: 414-607-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number2196
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: