=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245044791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRMONT REHABILITATION AND HEALTHCARE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2025
-----------------------------------------------------
Last Update Date | 02/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 KAUFMAN DR
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-2179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-363-5633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 229 ROUTE 70 FL 2
-----------------------------------------------------
City | TOMS RIVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08755-1026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED REPRESENTATIVE
-----------------------------------------------------
Name | REFOEL GOTTLIEB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-363-5633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------