- Enrollment id
- O20151120002749
- Enrollment state
- WV
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1295111565
- Multiple npi flag
- N
- Ccn
- 515021
- Associate id
- 5395045405
- Organization name
- FAIRHAVEN OPCO, LLC
- Doing business as name
- MADISON PARK HEALTHCARE
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- MADISON PARK HEALTHCARE
- Address line 1
- 700 MADISON AVE
- City
- HUNTINGTON
- State
- WV
- Zip code
- 257042630