Provider Demographics
NPI:1861884199
Name:FMG WEST 36 1/2 STREET MINNESOTA LLC
Entity type:Organization
Organization Name:FMG WEST 36 1/2 STREET 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 1:4415 W 36 1/2 ST
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4854
Mailing Address - Country:US
Mailing Address - Phone:952-927-9717
Mailing Address - Fax:
Practice Address - Street 1:4415 W 36 1/2 ST
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4854
Practice Address - Country:US
Practice Address - Phone:952-927-9717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN245083Medicare Oscar/Certification