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General NPI Number Information
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NPI Number | 1205628062
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Entity Type | Organization
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Legal Business Name | RUSTIC MANOR HOMES, LLC
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Dates
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Enumeration Date | 05/19/2025
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Last Update Date | 05/19/2025
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Provider Practice Location Address
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Address Line | 2904 S CHICAGO AVE
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City | SOUTH MILWAUKEE
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State | WI
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Zip | 53172-3134
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Country | US
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Telephone | 262-353-1910
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Fax | 262-353-1910
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Provider Business Mailing Address
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Address Line | 3383 E LAYTON AVE
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City | CUDAHY
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State | WI
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Zip | 53110-1437
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Country | US
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Telephone | 414-485-7088
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Fax | 414-485-7088
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Authorized Official
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Title or Position | DIRECTOR
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Name | CYNTHIA SIMPSON
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Credential |
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Telephone | 262-353-1910
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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