Provider Demographics
NPI:1740679547
Name:FMG NEW PINE DRIVE WISCONSIN LLC
Entity type:Organization
Organization Name:FMG NEW PINE DRIVE WISCONSIN 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 1:2512 NEW PINE DR
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-1378
Mailing Address - Country:US
Mailing Address - Phone:715-833-0400
Mailing Address - Fax:715-833-0546
Practice Address - Street 1:2512 NEW PINE DR
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-1378
Practice Address - Country:US
Practice Address - Phone:715-833-0400
Practice Address - Fax:715-833-0546
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
WI525454Medicare Oscar/Certification