# FMG RANDOM LANE MICHIGAN LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1629452214
- **Authorized official:** DAVID KEATING (AUTHORIZED OFFICIAL)
- **Authorized official phone:** (414) 908-8058

## Contact information

- **Practice address:** 508 RANDOM LN, GAYLORD, MI 49735-9304
- **Practice address phone:** (989) 732-2508
- **Practice address fax:** (989) 731-5260
- **Mailing address:** 508 RANDOM LN, GAYLORD, MI 49735-9304
- **Mailing address phone:** (989) 732-2508
- **Mailing address fax:** (989) 731-5260

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | — | NULL | Yes |

## Other

- **Enumeration date:** 07/14/2015
- **Last updated:** 07/14/2015