Healthcare Provider Details

I. General information

NPI: 1386042711
Provider Name (Legal Business Name): FMG SOUTH HURON STREET MICHIGAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2014
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 S HURON ST
CHEBOYGAN MI
49721-2210
US

IV. Provider business mailing address

824 S HURON ST
CHEBOYGAN MI
49721-2210
US

V. Phone/Fax

Practice location:
  • Phone: 231-627-4347
  • Fax: 231-627-4883
Mailing address:
  • Phone: 231-627-4347
  • Fax: 231-627-4883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: DAVID KEATING
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 414-908-8058