=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922887876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GUARDIAN MANOR L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2023
-----------------------------------------------------
Last Update Date | 09/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6709 W CHAMBERS ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53210-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-469-0100
-----------------------------------------------------
Fax | 866-480-8397
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PMB 181 3900 W. BROWN DEER RD
-----------------------------------------------------
City | BROWN DEER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-469-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL COORDINATOR
-----------------------------------------------------
Name | ERICA LE MAY
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 414-469-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0630X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------