Provider Demographics
NPI:1861488231
Name:FAIRMONT CARE CENTRE, INC.
Entity Type:Organization
Organization Name:FAIRMONT CARE CENTRE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:VICERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-604-4416
Mailing Address - Street 1:5061 N PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2706
Mailing Address - Country:US
Mailing Address - Phone:773-604-8112
Mailing Address - Fax:773-604-8113
Practice Address - Street 1:5061 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2706
Practice Address - Country:US
Practice Address - Phone:773-604-8112
Practice Address - Fax:773-604-8113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL000040493314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid