Provider Demographics
NPI:1700528650
Name:FAIRLANE GROUP HOME LLC
Entity type:Organization
Organization Name:FAIRLANE GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:GABRIELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MAC, CHT
Authorized Official - Phone:602-421-4663
Mailing Address - Street 1:16994 W RIO VISTA LN
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-7409
Mailing Address - Country:US
Mailing Address - Phone:602-421-4663
Mailing Address - Fax:602-610-5557
Practice Address - Street 1:821 W FAIRLANE CT
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6688
Practice Address - Country:US
Practice Address - Phone:602-421-4663
Practice Address - Fax:602-610-5557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-11
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility