Basic Information
Provider Information | |||||||||
NPI: | 1497701445 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAIRPORT ENTERPRISES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE LAURELS OF MASSILLON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8181 WORTHINGTON RD | ||||||||
Address2: |   | ||||||||
City: | WESTERVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 430828067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6147948800 | ||||||||
FaxNumber: | 6147948826 | ||||||||
Practice Location | |||||||||
Address1: | 2000 SHERMAN CIR NE | ||||||||
Address2: |   | ||||||||
City: | MASSILLON | ||||||||
State: | OH | ||||||||
PostalCode: | 446465219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3308309988 | ||||||||
FaxNumber: | 3308300039 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/25/2006 | ||||||||
LastUpdateDate: | 06/17/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KHAN | ||||||||
AuthorizedOfficialFirstName: | ANIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6147948800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 2082N | OH | N |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   | 314000000X | 2082N | OH | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 0283787 | 05 | OH |   | MEDICAID |