Healthcare Provider Details

I. General information

NPI: 1588894042
Provider Name (Legal Business Name): FAIRFAX HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2009
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 STABLE GLEN DR
PLANO TX
75025-2579
US

IV. Provider business mailing address

7900 STABLE GLEN DR
PLANO TX
75025-2579
US

V. Phone/Fax

Practice location:
  • Phone: 972-517-7921
  • Fax:
Mailing address:
  • Phone: 972-517-7921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. RICKY MULOWENI
Title or Position: VICE PRESIDENT
Credential:
Phone: 972-517-7921