Provider Demographics
NPI:1902016090
Name:MARY JUDE HEALTH CARE, INC.
Entity Type:Organization
Organization Name:MARY JUDE HEALTH CARE, INC.
Other - Org Name:MARY JUDE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FRISBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-543-5330
Mailing Address - Street 1:9806 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2234
Mailing Address - Country:US
Mailing Address - Phone:414-543-5330
Mailing Address - Fax:
Practice Address - Street 1:9806 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2234
Practice Address - Country:US
Practice Address - Phone:414-543-5330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2962314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20163400Medicaid
WI20163400Medicaid