Healthcare Provider Details

I. General information

NPI: 1851780290
Provider Name (Legal Business Name): FMG 26TH AVENUE WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 26TH AVE
MONROE WI
53566-1531
US

IV. Provider business mailing address

516 26TH AVE
MONROE WI
53566-1531
US

V. Phone/Fax

Practice location:
  • Phone: 608-325-9141
  • Fax: 608-329-6594
Mailing address:
  • Phone: 608-325-9141
  • Fax: 608-329-6594

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