Provider Demographics
NPI:1306835905
Name:INNER CITY NURSING HOME INC
Entity Type:Organization
Organization Name:INNER CITY NURSING HOME INC
Other - Org Name:FAIRFAX HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:PYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-795-1363
Mailing Address - Street 1:9014 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-2932
Mailing Address - Country:US
Mailing Address - Phone:216-795-1363
Mailing Address - Fax:216-795-1573
Practice Address - Street 1:9014 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-2932
Practice Address - Country:US
Practice Address - Phone:216-795-1363
Practice Address - Fax:216-795-1573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0713314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0364369Medicaid
OH0364369Medicaid