Basic Information
| Provider Information | |||||||||
| NPI: | 1790311082 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FHS FAIRLAWN, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TIMBERLAND RIDGE NURSING & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25000 COUNTRY CLUB BLVD STE 255 | ||||||||
| Address2: | |||||||||
| City: | NORTH OLMSTED | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440705337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407932245 | ||||||||
| FaxNumber: | 4406140168 | ||||||||
| Practice Location | |||||||||
| Address1: | 3558 RIDGEWOOD RD | ||||||||
| Address2: | |||||||||
| City: | FAIRLAWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443333122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304720296 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2020 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PARKER | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3305546619 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0399228 | 05 | OH | MEDICAID |