Provider Demographics
NPI:1437487758
Name:FAIRFAX COMMUNITY HOME HEALTH
Entity Type:Organization
Organization Name:FAIRFAX COMMUNITY HOME HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SANDMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-426-8241
Mailing Address - Street 1:300 10TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:MN
Mailing Address - Zip Code:55332-2149
Mailing Address - Country:US
Mailing Address - Phone:507-426-8241
Mailing Address - Fax:507-426-7340
Practice Address - Street 1:300 10TH AVE SE
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:MN
Practice Address - Zip Code:55332-2149
Practice Address - Country:US
Practice Address - Phone:507-426-8241
Practice Address - Fax:507-426-7340
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRFAX COMMUNITY HOME INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN345866251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN030802015OtherPRIMEWEST HEALTH
MN138740500Medicaid
MN138740500Medicaid