Provider Demographics
NPI:1205228525
Name:FMG NORTH WISCONSIN STREET WISCONSIN LLC
Entity Type:Organization
Organization Name:FMG NORTH WISCONSIN STREET WISCONSIN LLC
Other - Org Name:HERITAGE NURSING AND REHABILITATION CENTER
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 1:1119 N WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1209
Mailing Address - Country:US
Mailing Address - Phone:262-284-5892
Mailing Address - Fax:262-284-0234
Practice Address - Street 1:1119 N WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1209
Practice Address - Country:US
Practice Address - Phone:262-284-5892
Practice Address - Fax:262-284-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI525586Medicare Oscar/Certification