Provider Demographics
NPI:1568463818
Name:FAIRMOUNT HOMES
Entity Type:Organization
Organization Name:FAIRMOUNT HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-354-1800
Mailing Address - Street 1:333 WHEAT RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-8558
Mailing Address - Country:US
Mailing Address - Phone:717-354-1800
Mailing Address - Fax:717-354-6665
Practice Address - Street 1:333 WHEAT RIDGE DR
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-8558
Practice Address - Country:US
Practice Address - Phone:717-354-1800
Practice Address - Fax:717-354-6665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA060202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007566860002Medicaid
PA395805Medicare ID - Type Unspecified