Healthcare Provider Details

I. General information

NPI: 1962894295
Provider Name (Legal Business Name): FMG SOUTH RAPIDS ROAD WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2015
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 S RAPIDS RD
MANITOWOC WI
54220-4146
US

IV. Provider business mailing address

960 S RAPIDS RD
MANITOWOC WI
54220-4146
US

V. Phone/Fax

Practice location:
  • Phone: 920-684-1144
  • Fax:
Mailing address:
  • Phone: 920-684-1144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

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