Healthcare Provider Details

I. General information

NPI: 1720317605
Provider Name (Legal Business Name): THE FAIRWAYS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30630 RIDGE RD
WICKLIFFE OH
44092-1166
US

IV. Provider business mailing address

30630 RIDGE RD
WICKLIFFE OH
44092-1166
US

V. Phone/Fax

Practice location:
  • Phone: 440-943-2050
  • Fax: 440-943-0403
Mailing address:
  • Phone: 440-943-2050
  • Fax: 440-943-0403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2201R
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number2201R
License Number StateOH

VIII. Authorized Official

Name: MR. JEFFREY KNIGHT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 440-943-2050