Healthcare Provider Details

I. General information

NPI: 1902016090
Provider Name (Legal Business Name): MARY JUDE HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9806 W LINCOLN AVE
WEST ALLIS WI
53227-2234
US

IV. Provider business mailing address

9806 W LINCOLN AVE
WEST ALLIS WI
53227-2234
US

V. Phone/Fax

Practice location:
  • Phone: 414-543-5330
  • Fax:
Mailing address:
  • Phone: 414-543-5330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2962
License Number StateWI

VIII. Authorized Official

Name: MICHAEL FRISBY
Title or Position: ADMINISTRATOR
Credential:
Phone: 414-543-5330