Provider Demographics
NPI:1396143665
Name:FMG NORTH STREET WEST MICHIGAN LLC
Entity type:Organization
Organization Name:FMG NORTH STREET WEST MICHIGAN LLC
Other - Org Name:<UNAVAIL>
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 1:400 NORTH ST W
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-9161
Mailing Address - Country:US
Mailing Address - Phone:989-362-8645
Mailing Address - Fax:989-362-4462
Practice Address - Street 1:400 NORTH ST W
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9161
Practice Address - Country:US
Practice Address - Phone:989-362-8645
Practice Address - Fax:989-362-4462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
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
MI235379Medicare Oscar/Certification