Healthcare Provider Details

I. General information

NPI: 1134196983
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

8615 W BELOIT RD
WEST ALLIS WI
53227-3711
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: 414-607-4502
Mailing address:
  • Phone: 414-607-4100
  • Fax: 414-607-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number2153
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number2153
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2153
License Number StateWI

VIII. Authorized Official

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