Healthcare Provider Details

I. General information

NPI: 1962594630
Provider Name (Legal Business Name): FAIRHAVEN REST HOME, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MADISON AVE
HUNTINGTON WV
25704-2630
US

IV. Provider business mailing address

700 MADISON AVE P. O. BOX 2806
HUNTINGTON WV
25704-2630
US

V. Phone/Fax

Practice location:
  • Phone: 304-522-0032
  • Fax: 304-522-1481
Mailing address:
  • Phone: 304-522-0032
  • Fax: 304-522-1481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2
License Number StateWV

VIII. Authorized Official

Name: MRS. BARBARA P. MCCALL
Title or Position: ADMINISTRATOR
Credential:
Phone: 304-522-0032