Provider Demographics
NPI:1497841324
Name:FAIRFAX MANOR LLC
Entity Type:Organization
Organization Name:FAIRFAX MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-775-4439
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-0429
Mailing Address - Country:US
Mailing Address - Phone:918-775-4439
Mailing Address - Fax:918-775-9242
Practice Address - Street 1:210 EAST CHOCTAW STREET
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-0429
Practice Address - Country:US
Practice Address - Phone:918-775-4439
Practice Address - Fax:918-775-9242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH5702-5702313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375467Medicare ID - Type UnspecifiedMEDICARE