Provider Demographics
NPI:1629452214
Name:FMG RANDOM LANE MICHIGAN LLC
Entity Type:Organization
Organization Name:FMG RANDOM LANE MICHIGAN LLC
Other - Org Name:
Other - Org Type:
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 1:508 RANDOM LN
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9304
Mailing Address - Country:US
Mailing Address - Phone:989-732-2508
Mailing Address - Fax:989-731-5260
Practice Address - Street 1:508 RANDOM LN
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9304
Practice Address - Country:US
Practice Address - Phone:989-732-2508
Practice Address - Fax:989-731-5260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235350Medicare Oscar/Certification