Provider Demographics
NPI:1477859841
Name:FAIRVIEW COMMUNITY PERSONAL CARE HOME, INC.
Entity Type:Organization
Organization Name:FAIRVIEW COMMUNITY PERSONAL CARE HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTILIA
Authorized Official - Middle Name:MAURICE
Authorized Official - Last Name:TRIPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-570-3149
Mailing Address - Street 1:2470 FAIRVIEW RD SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-4919
Mailing Address - Country:US
Mailing Address - Phone:770-785-7800
Mailing Address - Fax:678-609-1387
Practice Address - Street 1:2470 FAIRVIEW RD SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-4919
Practice Address - Country:US
Practice Address - Phone:770-785-7800
Practice Address - Fax:678-609-1387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA107-01-054-13104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness