Provider Demographics
NPI:1003315961
Name:FAIRVIEW MANOR, INC.
Entity Type:Organization
Organization Name:FAIRVIEW MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:VICENTE
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-331-0980
Mailing Address - Street 1:1310 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3647
Mailing Address - Country:US
Mailing Address - Phone:407-331-0980
Mailing Address - Fax:407-622-1443
Practice Address - Street 1:1310 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3647
Practice Address - Country:US
Practice Address - Phone:407-331-0980
Practice Address - Fax:407-622-1443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12826310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility