Provider Demographics
NPI:1568450252
Name:FAIRFIELD HOME, LLC
Entity Type:Organization
Organization Name:FAIRFIELD HOME, LLC
Other - Org Name:FAIRFIELD HEALTH CARE CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-358-5200
Mailing Address - Street 1:1709 MILL STREET
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-2730
Mailing Address - Country:US
Mailing Address - Phone:803-337-2257
Mailing Address - Fax:
Practice Address - Street 1:117 BELLFIELD ROAD
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:SC
Practice Address - Zip Code:29130-8261
Practice Address - Country:US
Practice Address - Phone:803-337-2257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH-776314000000X
SC0978314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0776NFMedicaid
SC42-5158Medicare ID - Type Unspecified