Healthcare Provider Details

I. General information

NPI: 1194180489
Provider Name (Legal Business Name): FAIRHAVEN OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2015
Last Update Date: 12/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MADISON AVE
HUNTINGTON WV
25704-2630
US

IV. Provider business mailing address

121 S WATER AVE
GALLATIN TN
37066-2902
US

V. Phone/Fax

Practice location:
  • Phone: 304-552-0032
  • Fax: 304-522-1481
Mailing address:
  • Phone: 423-290-2837
  • Fax: 888-278-3162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. ISAAC S DOLE
Title or Position: MANAGER
Credential:
Phone: 312-724-8950