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General NPI Number Information
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NPI Number | 1710970926
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Entity Type | Organization
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Legal Business Name | FAIRHAVEN CHRISTIAN RETIREMENT CENTER
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Dates
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Enumeration Date | 08/24/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3470 N ALPINE RD
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City | ROCKFORD
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State | IL
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Zip | 61114-4802
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Country | US
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Telephone | 815-877-1441
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Fax | 815-877-2040
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Provider Business Mailing Address
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Address Line | 3470 N ALPINE RD
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City | ROCKFORD
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State | IL
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Zip | 61114-4802
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Country | US
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Telephone | 815-877-1441
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Fax | 815-877-2040
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Authorized Official
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Title or Position | ASSISTANT ADMIN./DIR OF FINANCE
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Name | JEFFREY R. REIERSON
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Credential | NHA,CPA
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Telephone | 815-877-1441
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | 1676858
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License Number State | IL
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