Provider Demographics
NPI:1952378648
Name:METHODIST MANOR OF WAUKESHA, INC.
Entity Type:Organization
Organization Name:METHODIST MANOR OF WAUKESHA, INC.
Other - Org Name:RUTH HOSPICE
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 1:8526 W MILL RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-1934
Practice Address - Country:US
Practice Address - Phone:414-607-4710
Practice Address - Fax:414-607-4711
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 Licenses
StateLicense IDTaxonomies
WI2002251G00000X, 315D00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
No251G00000XAgenciesHospice Care, Community Based
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2002OtherFACILITY LICENSE NUMBER
WI43190000Medicaid
WI43190000Medicaid
WI43190000Medicaid