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NPI Code Detail

MEDICARE: FAIRHAVEN CORPORATION

MEDICARE: FAIRHAVEN CORPORATION
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
1314000000XSkilled Nursing Facility1039WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1083619761
Entity Type Code : Organization
Provider Name (Legal Business Name) : FAIRHAVEN CORPORATION
Provider Business Mailing Address
First Line : 435 W STARIN RD
Second Line :
City : WHITEWATER
State : WI
Zip : 53190-1133
Country : US
Telephone Number : 262-473-3445
Fax Number : 262-473-5468
Provider Business Practice Location Address
First Line : 435 W STARIN RD
Second Line :
City : WHITEWATER
State : WI
Zip : 53190-1133
Country : US
Telephone Number : 262-473-3445
Fax Number : 262-473-5468
Authorized Official
Title or Position : DIRECTOR OF HR/BUSINESS SERVICES
Name : DAVID GACKSTATTER
Credential :
Telephone Number : 608-322-4331
Provider Enumeration Date : 06/17/2005
Last Update Date : 09/01/2020

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