Provider Demographics
NPI:1669403499
Name:MELLEN MANOR LLC
Entity type:Organization
Organization Name:MELLEN MANOR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:320-828-7310
Mailing Address - Street 1:450 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MELLEN
Mailing Address - State:WI
Mailing Address - Zip Code:54546-9750
Mailing Address - Country:US
Mailing Address - Phone:715-274-5706
Mailing Address - Fax:715-274-2702
Practice Address - Street 1:450 LAKE DR
Practice Address - Street 2:
Practice Address - City:MELLEN
Practice Address - State:WI
Practice Address - Zip Code:54546-9750
Practice Address - Country:US
Practice Address - Phone:715-274-5706
Practice Address - Fax:715-274-2702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314000000X314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20120500Medicaid
WI100103573Medicaid