Provider Demographics
NPI:1528219938
Name:FAIR HAVENS CHRISTIAN HOME, INC.
Entity Type:Organization
Organization Name:FAIR HAVENS CHRISTIAN HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGHEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-587-7903
Mailing Address - Street 1:1790 S FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-4010
Mailing Address - Country:US
Mailing Address - Phone:217-429-2551
Mailing Address - Fax:217-429-2942
Practice Address - Street 1:1790 S FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-4010
Practice Address - Country:US
Practice Address - Phone:217-429-2551
Practice Address - Fax:217-429-2942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0018143332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========801Medicaid