Healthcare Provider Details

I. General information

NPI: 1083002141
Provider Name (Legal Business Name): FMG NORTH GARRISON ROAD WASHINGTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2014
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 N GARRISON RD
VANCOUVER WA
98664-1354
US

IV. Provider business mailing address

1015 N GARRISON RD
VANCOUVER WA
98664-1354
US

V. Phone/Fax

Practice location:
  • Phone: 360-694-7501
  • Fax: 360-694-8148
Mailing address:
  • Phone: 360-694-7501
  • Fax: 360-694-8148

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