Provider Demographics
NPI:1710970926
Name:FAIRHAVEN CHRISTIAN RETIREMENT CENTER
Entity Type:Organization
Organization Name:FAIRHAVEN CHRISTIAN RETIREMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMIN./DIR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:REIERSON
Authorized Official - Suffix:
Authorized Official - Credentials:NHA,CPA
Authorized Official - Phone:815-877-1441
Mailing Address - Street 1:3470 N ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-4802
Mailing Address - Country:US
Mailing Address - Phone:815-877-1441
Mailing Address - Fax:815-877-2040
Practice Address - Street 1:3470 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4802
Practice Address - Country:US
Practice Address - Phone:815-877-1441
Practice Address - Fax:815-877-2040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1676858313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0027987Medicaid