Basic Information
| Provider Information | |||||||||
| NPI: | 1548658602 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FMG FIRST AVENUE NORTHWEST MINNESOTA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTH AND REHABILITATION OF NEW BRIGHTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 1ST AVE NW | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551126846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516337875 | ||||||||
| FaxNumber: | 6516289335 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 1ST AVE NW | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551126846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516337875 | ||||||||
| FaxNumber: | 6516289335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2014 | ||||||||
| LastUpdateDate: | 12/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | KEATING | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4149088058 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.