Provider Demographics
NPI:1386636116
Name:FAIRFAX NURSING CENTER, INC
Entity Type:Organization
Organization Name:FAIRFAX NURSING CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:BAINUM
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-273-7705
Mailing Address - Street 1:10701 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6904
Mailing Address - Country:US
Mailing Address - Phone:703-273-7705
Mailing Address - Fax:703-273-8077
Practice Address - Street 1:10701 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6904
Practice Address - Country:US
Practice Address - Phone:703-273-7705
Practice Address - Fax:703-273-9066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2552314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA442051OtherANTHEM BC/BS PROVIDER NO.
VA0573480001OtherMC B DME PROVIDER NUMBER
VA004950992Medicaid
VA442051OtherANTHEM BC/BS PROVIDER NO.