# FAIRLANE GROUP HOME LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1700528650
- **Authorized official:** MRS. GABRIELLA FOSTER MAC, CHT (DIRECTOR OF OPERATIONS)
- **Authorized official phone:** (602) 421-4663

## Contact information

- **Practice address:** 821 W FAIRLANE CT, CASA GRANDE, AZ 85122-6688
- **Practice address phone:** (602) 421-4663
- **Practice address fax:** (602) 610-5557
- **Mailing address:** 16994 W RIO VISTA LN, GOODYEAR, AZ 85338-7409
- **Mailing address phone:** (602) 421-4663
- **Mailing address fax:** (602) 610-5557

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 323P00000X | Psychiatric Residential Treatment Facility | — | NULL | Yes |

## Other

- **Enumeration date:** 04/11/2022
- **Last updated:** 04/12/2022