Provider Demographics
NPI:1538136254
Name:METHODIST MANOR HEALTH CENTER, INC.
Entity type:Organization
Organization Name:METHODIST MANOR HEALTH CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ENLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-607-4100
Mailing Address - Street 1:3023 S 84TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-3703
Mailing Address - Country:US
Mailing Address - Phone:414-607-4100
Mailing Address - Fax:414-607-4502
Practice Address - Street 1:8520 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-4604
Practice Address - Country:US
Practice Address - Phone:414-607-4291
Practice Address - Fax:414-607-4530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QH0700X, 261Q00000X, 261QM0850X, 261QM2500X, 261QP2000X, 261QP2300X, 261QR0400X, 261QX0100X, 207QG0300X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and SpeechGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32865700Medicaid
WI32865700Medicaid
WI02765Medicare UPIN