Provider Demographics
NPI:1962594630
Name:FAIRHAVEN REST HOME, INC
Entity type:Organization
Organization Name:FAIRHAVEN REST HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-522-0032
Mailing Address - Street 1:700 MADISON AVE
Mailing Address - Street 2:P. O. BOX 2806
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704-2630
Mailing Address - Country:US
Mailing Address - Phone:304-522-0032
Mailing Address - Fax:304-522-1481
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:304-522-0032
Practice Address - Fax:304-522-1481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0003341000Medicaid
WV515021Medicare Oscar/Certification