Provider Demographics
NPI:1770995094
Name:FAIR HAVEN OF FOREST CITY LLC
Entity type:Organization
Organization Name:FAIR HAVEN OF FOREST CITY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CILONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-245-9095
Mailing Address - Street 1:149 FAIRHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:BOSTIC
Mailing Address - State:NC
Mailing Address - Zip Code:28018-8759
Mailing Address - Country:US
Mailing Address - Phone:828-245-9095
Mailing Address - Fax:828-245-7856
Practice Address - Street 1:830 BETHANY CHURCH RD
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-8106
Practice Address - Country:US
Practice Address - Phone:828-245-2852
Practice Address - Fax:828-248-2590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0474310400000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC345314Medicare Oscar/Certification