Provider Demographics
NPI:1710425509
Name:FAIR HAVENS CHRISTIAN HOME, INC.
Entity Type:Organization
Organization Name:FAIR HAVENS CHRISTIAN HOME, INC.
Other - Org Name:HICKORY POINT CHRISTIAN VILLAGE
Other - Org Type:Doing Business As
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 1:565 W MARION AVE
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535-2099
Mailing Address - Country:US
Mailing Address - Phone:217-872-1122
Mailing Address - Fax:
Practice Address - Street 1:565 W MARION AVE
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-2099
Practice Address - Country:US
Practice Address - Phone:217-872-1122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIR HAVENS CHRISTIAN HOME, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0050682261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL146148Medicare Oscar/Certification