Provider Demographics
NPI:1619944303
Name:METHODIST MANOR OF WAUKESHA, INC.
Entity Type:Organization
Organization Name:METHODIST MANOR OF WAUKESHA, INC.
Other - Org Name:GREENVILLE MANOR
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:W7098 BUTTERCUP CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:WI
Practice Address - Zip Code:54942-9048
Practice Address - Country:US
Practice Address - Phone:920-757-0996
Practice Address - Fax:920-757-0973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-02
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========OtherTAX ID#
WI390942151Medicare ID - Type UnspecifiedMEDICARE/FEDERAL ID#