Basic Information
Provider Information | |||||||||
NPI: | 1245638543 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FMG CLARE AVENUE WASHINGTON LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5001 WEST LEMON STREET | ||||||||
Address2: | C/O FOCUS MANAGEMENT GROUP | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336091103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8132810062 | ||||||||
FaxNumber: | 8132810063 | ||||||||
Practice Location | |||||||||
Address1: | 2701 CLARE AVE | ||||||||
Address2: |   | ||||||||
City: | BREMERTON | ||||||||
State: | WA | ||||||||
PostalCode: | 983103313 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603773951 | ||||||||
FaxNumber: | 3603775443 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2014 | ||||||||
LastUpdateDate: | 11/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KEATING | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | C. | ||||||||
AuthorizedOfficialTitleorPosition: | AGENT | ||||||||
AuthorizedOfficialTelephone: | 4149088058 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.