Provider Demographics
NPI:1548658602
Name:FMG FIRST AVENUE NORTHWEST MINNESOTA LLC
Entity type:Organization
Organization Name:FMG FIRST AVENUE NORTHWEST MINNESOTA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KEATING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-908-8058
Mailing Address - Street 1:825 1ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-6846
Mailing Address - Country:US
Mailing Address - Phone:651-633-7875
Mailing Address - Fax:651-628-9335
Practice Address - Street 1:825 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6846
Practice Address - Country:US
Practice Address - Phone:651-633-7875
Practice Address - Fax:651-628-9335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-24
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN245164Medicare Oscar/Certification