Provider Demographics
NPI:1710376512
Name:FMG NORTH SUMMIT VILLAGE WAY WISCONSIN LLC
Entity Type:Organization
Organization Name:FMG NORTH SUMMIT VILLAGE WAY WISCONSIN LLC
Other - Org Name:LAKE COUNTRY HEALTH & REHABILITATION
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 1:2195 N SUMMIT VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:WI
Mailing Address - Zip Code:53066-8675
Mailing Address - Country:US
Mailing Address - Phone:262-567-4662
Mailing Address - Fax:
Practice Address - Street 1:2195 N SUMMIT VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066-8675
Practice Address - Country:US
Practice Address - Phone:262-567-4662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
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
WI525702Medicare Oscar/Certification