Provider Demographics
NPI:1730748575
Name:FAIRVIEW REHABILITATION & HEALTHCARE LLC
Entity type:Organization
Organization Name:FAIRVIEW REHABILITATION & HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:618-294-8696
Mailing Address - Street 1:215 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-1504
Mailing Address - Country:US
Mailing Address - Phone:618-294-8696
Mailing Address - Fax:618-294-8699
Practice Address - Street 1:602 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-2429
Practice Address - Country:US
Practice Address - Phone:618-542-3441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37092391001Medicaid