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General NPI Number Information
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NPI Number | 1851711899
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Entity Type | Organization
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Legal Business Name | THE MANNA HOUSE ADULT FAMILY HOME
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Dates
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Enumeration Date | 04/17/2014
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Last Update Date | 04/29/2014
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Provider Practice Location Address
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Address Line | 3417 DOUGLAS AVE
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City | RACINE
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State | WI
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Zip | 53402-3751
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Country | US
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Telephone | 262-637-8362
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Fax | 262-800-3065
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Provider Business Mailing Address
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Address Line | 2400 KINZIE AVE
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City | RACINE
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State | WI
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Zip | 53405-2520
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Country | US
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Telephone | 262-637-8362
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Fax | 262-800-3065
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Authorized Official
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Title or Position | OWNER
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Name | MRS. BEATRICE JOHNSON
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Credential |
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Telephone | 262-902-3338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number | 0015034
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License Number State | WI
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