Provider Demographics
NPI:1114923935
Name:CLEMENT MANOR, INC.
Entity Type:Organization
Organization Name:CLEMENT MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-546-7330
Mailing Address - Street 1:3939 S 92ND ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-2140
Mailing Address - Country:US
Mailing Address - Phone:414-321-1800
Mailing Address - Fax:414-546-7357
Practice Address - Street 1:3939 S 92ND ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-2140
Practice Address - Country:US
Practice Address - Phone:414-321-1800
Practice Address - Fax:414-546-7357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2724314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20113300Medicaid
WI20113300Medicaid