Healthcare Provider Details

I. General information

NPI: 1720638521
Provider Name (Legal Business Name): FAIR HAVENS SENIOR LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
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:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SARAH DUJUA
Title or Position: DIRECTOR OF AR
Credential:
Phone: 630-217-1014