Healthcare Provider Details

I. General information

NPI: 1124483714
Provider Name (Legal Business Name): MEADOWMERE AND MITCHELL MANOR SENIOR LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 W LINCOLN AVE
WEST ALLIS WI
53219-1652
US

IV. Provider business mailing address

5301 W LINCOLN AVE
WEST ALLIS WI
53219-1652
US

V. Phone/Fax

Practice location:
  • Phone: 414-615-7200
  • Fax:
Mailing address:
  • Phone: 414-615-7200
  • Fax: 414-615-7184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4173-154
License Number StateWI

VIII. Authorized Official

Name: JENNIFER ETRINGER
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 414-615-7200