Provider Demographics
NPI:1568469740
Name:FAIRVIEW FELLOWSHIP HOME FOR SENIOR CITIZENS, INC.
Entity Type:Organization
Organization Name:FAIRVIEW FELLOWSHIP HOME FOR SENIOR CITIZENS, INC.
Other - Org Name:FAIRVIEW FELLOWSHIP HOME AND VILLAGE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:580-227-3783
Mailing Address - Street 1:605 E STATE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OK
Mailing Address - Zip Code:73737-1455
Mailing Address - Country:US
Mailing Address - Phone:580-227-3783
Mailing Address - Fax:580-227-3328
Practice Address - Street 1:605 E STATE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OK
Practice Address - Zip Code:73737-1455
Practice Address - Country:US
Practice Address - Phone:580-227-3783
Practice Address - Fax:580-227-3328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH4701313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375427Medicare ID - Type UnspecifiedMEDICARE