Provider Demographics
NPI:1700284148
Name:FMG WEST CITY PARK DRIVE MICHIGAN LLC
Entity Type:Organization
Organization Name:FMG WEST CITY PARK DRIVE MICHIGAN LLC
Other - Org Name:TENDERCARE HEALTH CENTER - MUNISING
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 1:300 CITY PARK DR
Mailing Address - Street 2:
Mailing Address - City:MUNISING
Mailing Address - State:MI
Mailing Address - Zip Code:49862-1130
Mailing Address - Country:US
Mailing Address - Phone:906-387-2273
Mailing Address - Fax:906-387-3922
Practice Address - Street 1:300 CITY PARK DR
Practice Address - Street 2:
Practice Address - City:MUNISING
Practice Address - State:MI
Practice Address - Zip Code:49862-1130
Practice Address - Country:US
Practice Address - Phone:906-387-2273
Practice Address - Fax:906-387-3922
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
MI235410Medicare Oscar/Certification