Healthcare Provider Details

I. General information

NPI: 1083630487
Provider Name (Legal Business Name): FAIR HAVENS CHRISTIAN HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 S FAIRVIEW AVE
DECATUR IL
62521-4010
US

IV. Provider business mailing address

1790 S FAIRVIEW AVE
DECATUR IL
62521-4010
US

V. Phone/Fax

Practice location:
  • Phone: 217-429-2551
  • Fax: 217-429-2942
Mailing address:
  • Phone: 217-429-2551
  • Fax: 217-429-2942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0018143
License Number StateIL

VIII. Authorized Official

Name: MRS. SUSAN MCGHEE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 314-587-7903