Provider Demographics
NPI:1801384979
Name:FAIRLIFE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:FAIRLIFE HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING / CEO
Authorized Official - Prefix:
Authorized Official - First Name:KOFI
Authorized Official - Middle Name:
Authorized Official - Last Name:KLU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-326-6103
Mailing Address - Street 1:2288 BLUE WATER BLVD STE 326
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-3311
Mailing Address - Country:US
Mailing Address - Phone:443-300-7158
Mailing Address - Fax:
Practice Address - Street 1:150 HIDDEN HILL CIR
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-4015
Practice Address - Country:US
Practice Address - Phone:301-326-6103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR4141251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5224014900Medicaid