Healthcare Provider Details

I. General information

NPI: 1386636116
Provider Name (Legal Business Name): FAIRFAX NURSING CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 08/07/2015
Certification Date:
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
22030-6904
US

V. Phone/Fax

Practice location:
  • Phone: 703-273-7705
  • Fax: 703-273-9066
Mailing address:
  • Phone: 703-273-7705
  • Fax: 703-273-8077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH2552
License Number StateVA

VIII. Authorized Official

Name: MS. RENEE BAINUM CARLSON
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 703-273-7705