Provider Demographics
NPI:1073128534
Name:FAIRFIELD COMMUNITY SUPPORTS
Entity Type:Organization
Organization Name:FAIRFIELD COMMUNITY SUPPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-216-4807
Mailing Address - Street 1:15663 STATE ROUTE 595
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-8850
Mailing Address - Country:US
Mailing Address - Phone:740-216-4807
Mailing Address - Fax:
Practice Address - Street 1:15663 STATE ROUTE 595
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-8850
Practice Address - Country:US
Practice Address - Phone:740-216-4807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0303222Medicaid