Healthcare Provider Details

I. General information

NPI: 1538136254
Provider Name (Legal Business Name): METHODIST MANOR HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8520 W OKLAHOMA AVE
WEST ALLIS WI
53227-4604
US

IV. Provider business mailing address

3023 S 84TH ST
WEST ALLIS WI
53227-3703
US

V. Phone/Fax

Practice location:
  • Phone: 414-607-4291
  • Fax: 414-607-4530
Mailing address:
  • Phone: 414-607-4100
  • Fax: 414-607-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateWI
# 6
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateWI
# 8
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateWI
# 9
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateWI
# 10
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number StateWI

VIII. Authorized Official

Name: MR. JAMES ENLUND
Title or Position: PRESIDENT & CEO
Credential:
Phone: 414-607-4100