=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619944303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METHODIST MANOR OF WAUKESHA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2006
-----------------------------------------------------
Last Update Date | 04/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | W7098 BUTTERCUP CT
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54942-9048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-757-0996
-----------------------------------------------------
Fax | 920-757-0973
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3023 S 84TH ST
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-3703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-607-4100
-----------------------------------------------------
Fax | 414-607-4502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | MR. JAMES ENLUND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-607-4100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------