Healthcare Provider Details

I. General information

NPI: 1104215060
Provider Name (Legal Business Name): FMG DAVIS STREET SNF WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 DAVIS ST
HAMMOND WI
54015-9615
US

IV. Provider business mailing address

425 DAVIS ST
HAMMOND WI
54015-9615
US

V. Phone/Fax

Practice location:
  • Phone: 715-796-2218
  • Fax: 715-796-5286
Mailing address:
  • Phone: 715-796-2218
  • Fax: 715-796-5286

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