Provider Demographics
NPI:1407229396
Name:DOLPHIN MANOR ADULT DAY PROGRAM
Entity Type:Organization
Organization Name:DOLPHIN MANOR ADULT DAY PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOLPHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-895-6666
Mailing Address - Street 1:4525 GUNDERSON RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-3711
Mailing Address - Country:US
Mailing Address - Phone:262-895-6666
Mailing Address - Fax:262-895-7091
Practice Address - Street 1:21404 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KANSASVILLE
Practice Address - State:WI
Practice Address - Zip Code:53139-9737
Practice Address - Country:US
Practice Address - Phone:262-895-6666
Practice Address - Fax:262-895-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management