Healthcare Provider Details

I. General information

NPI: 1376163725
Provider Name (Legal Business Name): FAERIELAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 06/14/2020
Certification Date: 06/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 EDGEWOOD ST FL 2
HARTFORD CT
06112-1917
US

IV. Provider business mailing address

470 EDGEWOOD ST FL 2
HARTFORD CT
06112-1917
US

V. Phone/Fax

Practice location:
  • Phone: 860-814-0771
  • Fax:
Mailing address:
  • Phone: 860-814-0771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SAPPHIRE R FAIRCHILD
Title or Position: MEMBER
Credential:
Phone: 860-814-0771