1083262398 NPI number — FELLOWSHIP HOME AT THE FAIRWAY

Table of content: (NPI 1083262398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083262398 NPI number — FELLOWSHIP HOME AT THE FAIRWAY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FELLOWSHIP HOME AT THE FAIRWAY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083262398
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALDOSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31603-5500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5959 SUN N LAKE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEBRING
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33872-2075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-385-5454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BACHMAN
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
863-385-5454

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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