Provider Demographics
NPI:1295111565
Name:FAIRHAVEN OPCO, LLC
Entity type:Organization
Organization Name:FAIRHAVEN OPCO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:S
Authorized Official - Last Name:DOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-724-8950
Mailing Address - Street 1:121 S WATER AVE
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-2902
Mailing Address - Country:US
Mailing Address - Phone:423-290-2837
Mailing Address - Fax:
Practice Address - Street 1:700 MADISON AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-2630
Practice Address - Country:US
Practice Address - Phone:304-552-0032
Practice Address - Fax:304-522-1481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-10
Last Update Date:2015-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
515021Medicare Oscar/Certification