MEDICARE: FAIRWAY PARK RETIREMENT FACILITY, CORP.

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	310400000X	Assisted Living Facility	10692	FL
2	310400000X	Assisted Living Facility	8673	FL

Other Identifiers

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

General Provider Information

NPI Number	:	1740430909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRWAY PARK RETIREMENT FACILITY, CORP.

Provider Business Mailing Address
First Line	:	16360 SW 92ND CT
Second Line	:
City	:	VILLAGE OF PALMETTO BAY
State	:	FL
Zip	:	33157-3460
Country	:	US
Telephone Number	:	786-286-4484
Fax Number	:

Provider Business Practice Location Address
First Line	:	16360 SW 92ND CT
Second Line	:
City	:	VILLAGE OF PALMETTO BAY
State	:	FL
Zip	:	33157-3460
Country	:	US
Telephone Number	:	786-286-4484
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARIE REGNIER
Credential	:
Telephone Number	:	786-286-4484

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	09/24/2008

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Directions to “FAIRWAY PARK RETIREMENT FACILITY, CORP. ” Practice Location

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