Provider Demographics
NPI:1104215060
Name:FMG DAVIS STREET SNF WISCONSIN LLC
Entity Type:Organization
Organization Name:FMG DAVIS STREET SNF WISCONSIN LLC
Other - Org Name:AMERICAN HERITAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KEATING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-908-8058
Mailing Address - Street 1:425 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54015-9615
Mailing Address - Country:US
Mailing Address - Phone:715-796-2218
Mailing Address - Fax:715-796-5286
Practice Address - Street 1:425 DAVIS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:WI
Practice Address - Zip Code:54015-9615
Practice Address - Country:US
Practice Address - Phone:715-796-2218
Practice Address - Fax:715-796-5286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-15
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI525499Medicare Oscar/Certification