Provider Demographics
NPI:1386101368
Name:FAIRVIEW AVENUE LLC
Entity type:Organization
Organization Name:FAIRVIEW AVENUE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROB
Authorized Official - Middle Name:
Authorized Official - Last Name:DEZSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-572-0070
Mailing Address - Street 1:3270 SUNTREE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7540
Mailing Address - Country:US
Mailing Address - Phone:321-549-0292
Mailing Address - Fax:407-572-0072
Practice Address - Street 1:3270 SUNTREE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7540
Practice Address - Country:US
Practice Address - Phone:321-549-0292
Practice Address - Fax:321-441-9747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-26
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009192400Medicaid