Provider Demographics
NPI:1235106576
Name:METHODIST MANOR HEALTH CENTER INC.
Entity Type:Organization
Organization Name:METHODIST MANOR HEALTH CENTER INC.
Other - Org Name:OLSEN MEDICAL CLINIC - TRINITY
Other - Org Type:Doing Business As
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 1:7300 W DEAN RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-2637
Practice Address - Country:US
Practice Address - Phone:414-371-7363
Practice Address - Fax:414-371-7334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207QG0300X, 261Q00000X, 261QH0100X, 261QM0850X, 261QP2000X, 261QR0400X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20194100Medicaid
WI=========OtherTAX ID#
WI=========OtherTAX ID#