Healthcare Provider Details

I. General information

NPI: 1033718382
Provider Name (Legal Business Name): FAIRFAX OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 12/25/2020
Certification Date: 12/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 MAIN ST
FAIRFAX VA
22030-6904
US

IV. Provider business mailing address

10701 MAIN ST
FAIRFAX VA
22030-6995
US

V. Phone/Fax

Practice location:
  • Phone: 703-273-7705
  • Fax: 703-273-0366
Mailing address:
  • Phone: 703-273-7705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ELAZAR FISCHER
Title or Position: CHIEF OF OPERATIONS
Credential:
Phone: 804-664-6046