Basic Information
| Provider Information | |||||||||
| NPI: | 1710375878 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FMG NORTHEAST WEIDLER STREET OREGON LLC | ||||||||
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| 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: | 11325 NE WEIDLER ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972201950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032531181 | ||||||||
| FaxNumber: | 5032531871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2014 | ||||||||
| LastUpdateDate: | 11/07/2017 | ||||||||
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| AuthorizedOfficialLastName: | KEATING | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | AGENT | ||||||||
| AuthorizedOfficialTelephone: | 4149088058 | ||||||||
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| 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.