1245638543 NPI number — FMG CLARE AVENUE WASHINGTON LLC

Table of content: (NPI 1245638543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245638543 NPI number — FMG CLARE AVENUE WASHINGTON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FMG CLARE AVENUE WASHINGTON LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245638543
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5001 WEST LEMON STREET
Provider Second Line Business Mailing Address:
C/O FOCUS MANAGEMENT GROUP
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33609-1103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-281-0062
Provider Business Mailing Address Fax Number:
813-281-0063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2701 CLARE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98310-3313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-377-3951
Provider Business Practice Location Address Fax Number:
360-377-5443
Provider Enumeration Date:
12/18/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KEATING
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
AGENT
Authorized Official Telephone Number:
414-908-8058

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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