Provider Demographics
NPI:1740430909
Name:FAIRWAY PARK RETIREMENT FACILITY, CORP.
Entity Type:Organization
Organization Name:FAIRWAY PARK RETIREMENT FACILITY, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:REGNIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-286-4484
Mailing Address - Street 1:16360 SW 92ND CT
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3460
Mailing Address - Country:US
Mailing Address - Phone:786-286-4484
Mailing Address - Fax:
Practice Address - Street 1:16360 SW 92ND CT
Practice Address - Street 2:
Practice Address - City:VILLAGE OF PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-3460
Practice Address - Country:US
Practice Address - Phone:786-286-4484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10692310400000X
FL8673310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142538200Medicaid
FL142405000Medicaid