Provider Demographics
NPI:1083187819
Name:FAIRHAVEN MEDICAL SUPPLY INC.
Entity Type:Organization
Organization Name:FAIRHAVEN MEDICAL SUPPLY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KASHIFA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-566-5801
Mailing Address - Street 1:625 BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-3020
Mailing Address - Country:US
Mailing Address - Phone:513-652-1452
Mailing Address - Fax:
Practice Address - Street 1:608 E HAWLEY ST
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1945
Practice Address - Country:US
Practice Address - Phone:847-566-5801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No335E00000XSuppliersProsthetic/Orthotic Supplier