Healthcare Provider Details

I. General information

NPI: 1124948450
Provider Name (Legal Business Name): FAIRVIEW HEALING HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20209 NE SAN RAFAEL ST
FAIRVIEW OR
97024-9682
US

IV. Provider business mailing address

20209 NE SAN RAFAEL ST
FAIRVIEW OR
97024-9682
US

V. Phone/Fax

Practice location:
  • Phone: 971-361-1987
  • Fax:
Mailing address:
  • Phone: 971-361-1987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ROGER UWIMANA
Title or Position: MEMBER
Credential:
Phone: 971-361-1987