Provider Demographics
NPI:1780080473
Name:BURR OAK MANOR, INC.
Entity type:Organization
Organization Name:BURR OAK MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PREDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-279-9990
Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-0304
Mailing Address - Country:US
Mailing Address - Phone:262-279-9990
Mailing Address - Fax:262-279-9922
Practice Address - Street 1:264 WALWORTH ST
Practice Address - Street 2:
Practice Address - City:GENOA CITY
Practice Address - State:WI
Practice Address - Zip Code:53128-2147
Practice Address - Country:US
Practice Address - Phone:262-279-9990
Practice Address - Fax:262-279-9622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3103213104A0625X, 3104A0630X, 311500000X, 313M00000X, 315D00000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient