Provider Demographics
NPI:1376818419
Name:FAIR OAKS RCF, LLC
Entity Type:Organization
Organization Name:FAIR OAKS RCF, LLC
Other - Org Name:FAIR OAKS CARE CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-391-2373
Mailing Address - Street 1:1201 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-2176
Mailing Address - Country:US
Mailing Address - Phone:712-246-2055
Mailing Address - Fax:712-246-2099
Practice Address - Street 1:1201 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-2176
Practice Address - Country:US
Practice Address - Phone:712-246-2055
Practice Address - Fax:712-246-2099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IANE PROPERTIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA730994313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1346434826Medicaid