Provider Demographics
NPI:1457759896
Name:FMG WEST FOURTH STREET MICHIGAN LLC
Entity Type:Organization
Organization Name:FMG WEST FOURTH STREET MICHIGAN LLC
Other - Org Name:TENDERCARE HEALTH CENTER OF LEELANAU
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 1:124 W FOURTH ST
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-9733
Mailing Address - Country:US
Mailing Address - Phone:231-271-1200
Mailing Address - Fax:231-271-1214
Practice Address - Street 1:124 W FOURTH ST
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682-9733
Practice Address - Country:US
Practice Address - Phone:231-271-1200
Practice Address - Fax:231-271-1214
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
MI235209Medicare Oscar/Certification