Provider Demographics
NPI:1386042711
Name:FMG SOUTH HURON STREET MICHIGAN LLC
Entity Type:Organization
Organization Name:FMG SOUTH HURON STREET MICHIGAN LLC
Other - Org Name:TENDERCARE HEALTH CENTER OF CHEBOYGAN
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 1:824 S HURON ST
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-2210
Mailing Address - Country:US
Mailing Address - Phone:231-627-4347
Mailing Address - Fax:231-627-4883
Practice Address - Street 1:824 S HURON ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-2210
Practice Address - Country:US
Practice Address - Phone:231-627-4347
Practice Address - Fax:231-627-4883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-17
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235566Medicare Oscar/Certification