Provider Demographics
NPI:1043755051
Name:FAIR OAKS RESIDENTIAL TREATMENT FACILITY
Entity Type:Organization
Organization Name:FAIR OAKS RESIDENTIAL TREATMENT FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-436-4291
Mailing Address - Street 1:7959 ORANGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-5916
Mailing Address - Country:US
Mailing Address - Phone:916-436-4291
Mailing Address - Fax:916-436-4338
Practice Address - Street 1:7959 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-5916
Practice Address - Country:US
Practice Address - Phone:916-436-4291
Practice Address - Fax:916-436-4338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550003745314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility