Provider Demographics
NPI:1215710678
Name:FAIRLAWN HAVEN
Entity type:Organization
Organization Name:FAIRLAWN HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:567-444-5083
Mailing Address - Street 1:407 E LUTZ RD
Mailing Address - Street 2:
Mailing Address - City:ARCHBOLD
Mailing Address - State:OH
Mailing Address - Zip Code:43502-1252
Mailing Address - Country:US
Mailing Address - Phone:419-445-3075
Mailing Address - Fax:567-444-5118
Practice Address - Street 1:500 HAVEN DR
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-1297
Practice Address - Country:US
Practice Address - Phone:419-445-3075
Practice Address - Fax:567-444-5118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRLAWN HAVEN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0708ROtherOHIO DEPARTMENT OF HEALTH FACILITY LICENSE