Provider Demographics
NPI:1811087018
Name:FAIRVIEW HEALTH OF SOUTHPORT, LLC
Entity type:Organization
Organization Name:FAIRVIEW HEALTH OF SOUTHPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLCE
Authorized Official - Suffix:
Authorized Official - Credentials:CONTROLLER
Authorized Official - Phone:203-259-7894
Mailing Address - Street 1:930 MILL HILL TER
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-1265
Mailing Address - Country:US
Mailing Address - Phone:203-259-7894
Mailing Address - Fax:203-254-3720
Practice Address - Street 1:930 MILL HILL TER
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1265
Practice Address - Country:US
Practice Address - Phone:203-259-7894
Practice Address - Fax:203-254-3720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2307-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000008508Medicaid
CT000008508Medicaid