Healthcare Provider Details

I. General information

NPI: 1336531656
Provider Name (Legal Business Name): FMG HOOVER STREET 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

1610 HOOVER ST
NEW HOLSTEIN WI
53061-1636
US

IV. Provider business mailing address

1610 HOOVER ST
NEW HOLSTEIN WI
53061-1636
US

V. Phone/Fax

Practice location:
  • Phone: 920-898-5706
  • Fax:
Mailing address:
  • Phone: 920-898-5706
  • Fax:

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