Provider Demographics
NPI:1013079177
Name:FAIRMONT HEALTHCARE CORP.
Entity type:Organization
Organization Name:FAIRMONT HEALTHCARE CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-338-4606
Mailing Address - Street 1:13907 AMAR RD
Mailing Address - Street 2:UNIT D
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91746-1676
Mailing Address - Country:US
Mailing Address - Phone:626-338-4606
Mailing Address - Fax:
Practice Address - Street 1:13907 E. AMAR RD
Practice Address - Street 2:UNIT D
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91746-1676
Practice Address - Country:US
Practice Address - Phone:626-338-4606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAADU70167GOtherPROVIDER NUMBER