Provider Demographics
NPI:1497701445
Name:FAIRPORT ENTERPRISES, INC.
Entity Type:Organization
Organization Name:FAIRPORT ENTERPRISES, INC.
Other - Org Name:THE LAURELS OF MASSILLON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-794-8800
Mailing Address - Street 1:8181 WORTHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-8067
Mailing Address - Country:US
Mailing Address - Phone:614-794-8800
Mailing Address - Fax:614-794-8826
Practice Address - Street 1:2000 SHERMAN CIR NE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-5219
Practice Address - Country:US
Practice Address - Phone:330-830-9988
Practice Address - Fax:330-830-0039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2082N313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0283787Medicaid
OH0283787Medicaid