Healthcare Provider Details

I. General information

NPI: 1578563441
Provider Name (Legal Business Name): FAIR OAKS REHABILITATION AND HEALTH CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 BLACKHAWK BLVD
SOUTH BELOIT IL
61080-2227
US

IV. Provider business mailing address

1515 BLACKHAWK BLVD
SOUTH BELOIT IL
61080-2227
US

V. Phone/Fax

Practice location:
  • Phone: 815-389-3911
  • Fax: 815-389-0565
Mailing address:
  • Phone: 815-389-3911
  • Fax: 815-389-0565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0043422
License Number StateIL

VIII. Authorized Official

Name: JOSEPH C TUTERA
Title or Position: PRESIDENT, CEO
Credential:
Phone: 816-444-0900