Provider Demographics
NPI:1023018504
Name:FAIR WINDS MANOR, LP
Entity type:Organization
Organization Name:FAIR WINDS MANOR, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-431-0770
Mailing Address - Street 1:126 IRON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SARVER
Mailing Address - State:PA
Mailing Address - Zip Code:16055-8603
Mailing Address - Country:US
Mailing Address - Phone:724-353-1531
Mailing Address - Fax:724-353-1117
Practice Address - Street 1:126 IRON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SARVER
Practice Address - State:PA
Practice Address - Zip Code:16055-8603
Practice Address - Country:US
Practice Address - Phone:724-353-1531
Practice Address - Fax:724-353-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2015-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA060102314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019292010001Medicaid
PA1511429OtherGATEWAY HEALTH PLAN
PA00000092631OtherTHREE RIVERS HEALTH PLAN
PAPENDINGOtherHIGHMARK BC
PAPENDINGOtherHIGHMARK BC