Provider Demographics
NPI:1649247453
Name:METHODIST MANOR INC
Entity type:Organization
Organization Name:METHODIST MANOR INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:414-607-4101
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:
Practice Address - Street 1:3023 S 84TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-3703
Practice Address - Country:US
Practice Address - Phone:414-607-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WINA-CBRF310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2013000Medicaid
WI525069Medicare ID - Type Unspecified