MEDICARE: FAIRHOPE RESIDENTIAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1033093844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRHOPE RESIDENTIAL LLC

Provider Business Mailing Address
First Line	:	20777 NOBLEMAN DR
Second Line	:
City	:	FAIRHOPE
State	:	AL
Zip	:	36532-4658
Country	:	US
Telephone Number	:	270-869-7934
Fax Number	:

Provider Business Practice Location Address
First Line	:	18874 SUMMER OAKS PL
Second Line	:
City	:	FAIRHOPE
State	:	AL
Zip	:	36532-4721
Country	:	US
Telephone Number	:	270-869-7934
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. JOHN THOMAS MICHAEL
Credential	:	RN
Telephone Number	:	270-869-7934

Provider Enumeration Date	:	08/04/2025
Last Update Date	:	08/04/2025

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