Healthcare Provider Details

I. General information

NPI: 1043755051
Provider Name (Legal Business Name): FAIR OAKS RESIDENTIAL TREATMENT FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2016
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7959 ORANGE AVE
FAIR OAKS CA
95628-5916
US

IV. Provider business mailing address

7959 ORANGE AVENUE
FAIR OAKS CA
95628-5916
US

V. Phone/Fax

Practice location:
  • Phone: 916-436-4291
  • Fax: 916-436-4338
Mailing address:
  • Phone: 916-436-4291
  • Fax: 916-436-4338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number550003745
License Number StateCA

VIII. Authorized Official

Name: MR. BRIAN MARTIN
Title or Position: CEO
Credential:
Phone: 916-436-4291