Provider Demographics
NPI:1083262398
Name:FELLOWSHIP HOME AT THE FAIRWAY
Entity Type:Organization
Organization Name:FELLOWSHIP HOME AT THE FAIRWAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BACHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-385-5454
Mailing Address - Street 1:PO BOX 5500
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31603-5500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5959 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-2075
Practice Address - Country:US
Practice Address - Phone:863-385-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-29
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility