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FMG WEST LACROSSE AVENUE IDAHO LLC

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Company Details

Name: FMG WEST LACROSSE AVENUE IDAHO LLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Inactive-Dissolved (Administrative)
Date of registration: 05 Nov 2014 (11 years ago)
Financial Date End: 30 Nov 2020
Date dissolved: 04 Feb 2021
Entity Number: 438755
Place of Formation: IDAHO
File Number: 438755
Principal Address: 111 W MICHIGAN ST MILWAUKEE, WI 53203
Mailing Address: PAT FOSTER STE 1085 330 E KILBOURN AVE MILWAUKEE, WI 53202-3146

Agent

Name Role Address
MIchael S Polsky Agent 330 EAST KILBOURN AVENUE, SUITE 1085, MILWAUKEE, ID 53202

Unique Entity ID

CAGE Code:
3TFY6
UEI Expiration Date:
2018-10-13

Business Information

Doing Business As:
LACROSSE HEALTH AND REHABILITATION CENTER
Activation Date:
2017-10-13
Initial Registration Date:
2015-07-22

Commercial and government entity program

CAGE number:
3TFY6
Status:
Obsolete
Type:
Non-Manufacturer
CAGE Update Date:
2022-10-15
CAGE Expiration:
2022-10-14

Contact Information

POC:
JESSE CARTER

National Provider Identifier

NPI Number:
1811385974

Authorized Person:

Name:
DAVID C. KEATING
Role:
SECRETARY AGENT
Phone:

Taxonomy:

Selected Taxonomy:
314000000X - Skilled Nursing Facility
Is Primary:
Yes

Contacts:

Fax:
8132810063
Fax:
2086641604

Filing

Filing Name Filing Number Filing date
Dissolution/Revocation - Administrative 0004160956 2021-02-04
Annual Report 0003684072 2019-11-25
Annual Report 0003352095 2018-11-23
Annual Report 0002863579 2017-10-25
Annual Report 0002863578 2016-11-22

USAspending Awards / Contracts

Procurement Instrument Identifier:
36C26019K0201
Award Or Idv Flag:
AWARD
Award Type:
DELIVERY ORDER
Action Obligation:
64227.72
Base And Exercised Options Value:
64227.72
Base And All Options Value:
64227.72
Awarding Agency Name:
Department of Veterans Affairs
Performance Start Date:
2018-06-01
Description:
EXPRESS REPORT FOR CNH PAID BY 1358
Naics Code:
623110: NURSING CARE FACILITIES (SKILLED NURSING FACILITIES)
Product Or Service Code:
Q402: MEDICAL- NURSING HOME CARE CONTRACTS
Procurement Instrument Identifier:
36C26019K0200
Award Or Idv Flag:
AWARD
Award Type:
DELIVERY ORDER
Action Obligation:
110779.78
Base And Exercised Options Value:
110779.78
Base And All Options Value:
110779.78
Awarding Agency Name:
Department of Veterans Affairs
Performance Start Date:
2018-04-01
Description:
EXPRESS REPORT FOR CNH PAID BY 1358
Naics Code:
623110: NURSING CARE FACILITIES (SKILLED NURSING FACILITIES)
Product Or Service Code:
Q402: MEDICAL- NURSING HOME CARE CONTRACTS
Procurement Instrument Identifier:
36C26019K0199
Award Or Idv Flag:
AWARD
Award Type:
DELIVERY ORDER
Action Obligation:
114941.53
Base And Exercised Options Value:
114941.53
Base And All Options Value:
114941.53
Awarding Agency Name:
Department of Veterans Affairs
Performance Start Date:
2018-02-01
Description:
EXPRESS REPORT FOR CNH PAID BY 1358
Naics Code:
623110: NURSING CARE FACILITIES (SKILLED NURSING FACILITIES)
Product Or Service Code:
Q402: MEDICAL- NURSING HOME CARE CONTRACTS

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Date of last update: 22 Jul 2025

Sources: Idaho Secretary of State