Healthcare Provider Details

I. General information

NPI: 1649247453
Provider Name (Legal Business Name): METHODIST MANOR 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

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

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberNA-CBRF
License Number StateWI

VIII. Authorized Official

Name: MR. JAMES ENLUND
Title or Position: PRESIDENT & CEO
Credential:
Phone: 414-607-4101