Provider Demographics
NPI:1205834355
Name:FGKG LLC
Entity Type:Organization
Organization Name:FGKG LLC
Other - Org Name:BRACE YOURSELF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZACH
Authorized Official - Middle Name:TYSON
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-395-3355
Mailing Address - Street 1:1620 RAIDERS WAY STE 140
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4631
Mailing Address - Country:US
Mailing Address - Phone:702-395-3555
Mailing Address - Fax:877-588-8501
Practice Address - Street 1:1620 RAIDERS WAY STE 140
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4631
Practice Address - Country:US
Practice Address - Phone:702-395-3555
Practice Address - Fax:877-588-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV928474785332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100510021Medicaid
NV=========OtherTAX IDENTIFICATION NUMBER
NV100510021Medicaid