Provider Demographics
NPI:1003813148
Name:FAIRLAWN HAVEN
Entity Type:Organization
Organization Name:FAIRLAWN HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTHCARE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:S
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-445-3075
Mailing Address - Street 1:407 E LUTZ RD
Mailing Address - Street 2:
Mailing Address - City:ARCHBOLD
Mailing Address - State:OH
Mailing Address - Zip Code:43502-1252
Mailing Address - Country:US
Mailing Address - Phone:419-445-3074
Mailing Address - Fax:
Practice Address - Street 1:407 E LUTZ RD
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-1252
Practice Address - Country:US
Practice Address - Phone:419-445-3074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0010302Medicaid
OH36-6290Medicare ID - Type Unspecified