Provider Demographics
NPI:1700760006
Name:TIMELESS MANOR LLC
Entity type:Organization
Organization Name:TIMELESS MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNWER
Authorized Official - Prefix:
Authorized Official - First Name:JAYMIA/ TEMEKO
Authorized Official - Middle Name:
Authorized Official - Last Name:PUTZEAR/ KNOWLWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-239-3274
Mailing Address - Street 1:3304 INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3304 INDIANA ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53405-4616
Practice Address - Country:US
Practice Address - Phone:414-239-3274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-01
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100324691Medicaid