Provider Demographics
NPI:1811385974
Name:FMG WEST LACROSSE AVENUE IDAHO LLC
Entity Type:Organization
Organization Name:FMG WEST LACROSSE AVENUE IDAHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY AGENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:KEATING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-908-8058
Mailing Address - Street 1:5001 WEST LEMON STREET
Mailing Address - Street 2:C/O FOCUS MANAGEMENT GROUP
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-1103
Mailing Address - Country:US
Mailing Address - Phone:813-281-0062
Mailing Address - Fax:813-281-0063
Practice Address - Street 1:210 W LACROSSE AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2403
Practice Address - Country:US
Practice Address - Phone:208-664-2185
Practice Address - Fax:208-664-1604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-24
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID135042Medicare Oscar/Certification