Provider Demographics
NPI:1063736213
Name:BLC THE FAIRWAYS LH LLC
Entity type:Organization
Organization Name:BLC THE FAIRWAYS LH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:LESKOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-918-5000
Mailing Address - Street 1:30630 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-1166
Mailing Address - Country:US
Mailing Address - Phone:440-943-2050
Mailing Address - Fax:
Practice Address - Street 1:30630 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092-1166
Practice Address - Country:US
Practice Address - Phone:440-943-2050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKDALE SENIOR LIVING INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-17
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2201R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3050728Medicaid