Healthcare Provider Details

I. General information

NPI: 1710963251
Provider Name (Legal Business Name): FAIRFAX COMMUNITY HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 05/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 10TH AVE SE
FAIRFAX MN
55332-2149
US

IV. Provider business mailing address

300 10TH AVE SE
FAIRFAX MN
55332-2149
US

V. Phone/Fax

Practice location:
  • Phone: 507-426-8241
  • Fax: 507-426-7340
Mailing address:
  • Phone: 507-426-8241
  • Fax: 507-426-7340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number328593
License Number StateMN

VIII. Authorized Official

Name: MRS. JUDITH A SANDMANN
Title or Position: ADMINISTRATOR
Credential:
Phone: 507-426-8241