Basic Information
| Provider Information | |||||||||
| NPI: | 1710376512 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FMG NORTH SUMMIT VILLAGE WAY WISCONSIN LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE COUNTRY HEALTH & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2195 N SUMMIT VILLAGE WAY | ||||||||
| Address2: | |||||||||
| City: | SUMMIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530668675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625674662 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2195 N SUMMIT VILLAGE WAY | ||||||||
| Address2: | |||||||||
| City: | SUMMIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530668675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625674662 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2015 | ||||||||
| LastUpdateDate: | 01/16/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| 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.