NPIMap

Organization Active NPI

Fairfax Healthcare, LLC

Doing business as Kennedy Care Center

  • Skilled Nursing Facility
  • Los Angeles, CA
National Provider Identifier
1639803182
Registry record updated Aug 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
FAIRFAX HEALTHCARE, LLC
Doing business as
Kennedy Care Center
Practice address
619 N Fairfax Ave
Los Angeles, CA 90036-1714
Phone
(323) 651-0043
NPI assigned
Jul 11, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 19, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John Mitchell
Title
Secretary
Phone
(385) 988-3319

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

619 N Fairfax Ave
Los Angeles, CA 90036-1714

Mailing address

262 N University Ave
Farmington, UT 84025-2975

Other names 1

  • Kennedy Care Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230424002264 CA Part A Provider - Skilled Nursing Facility 6800251976 Practice locations: Los Angeles, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1639803182. Details of each certification follow.

Skilled nursing facility certification: CCN 055977

Legal name
FAIRFAX HEALTHCARE, LLC
Doing business as
KENNEDY CARE CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Aug 21, 1968
Last certification
Jul 22, 2024
Beds
97
Ownership / control type
Limited Liability Corporation
Organization structure
LLCProprietary
Incorporated
Jun 14, 2022 in CA
Enrollment address
619 N Fairfax Ave
Los Angeles, CA 90036-1714
Nursing home name
KENNEDY CARE CENTER
Affiliated entity
PACS GROUP

Care Compare: Nursing home

Medicare Care Compare
Listed as
Kennedy Care CenterCCN 055977 · All quality measures
Overall star rating
1 of 5
Health inspections
1 of 5
Staffing
2 of 5
Quality measures
4 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Aug 21, 1968
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
9789.2 residents per day on average
Chain
Pacs Group274 facilities in the chain
Penalties (3 years)
2Fines totaling $38,272

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Locations

619 N Fairfax Ave
Los Angeles, CA 90036
Phone (323) 365-1004

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Jason H Murray Individual 5% Or Greater Indirect Ownership Interest Apr 15, 2024 41.8%
John T Mitchell Individual Corporate OfficerSecretary Jan 1, 2024
Alfred Rahban Individual Contracted Managing EmployeeMD; Jan 1, 2015
Frederick G Apt Individual Corporate OfficerTreasurer Jan 1, 2024
Andrew Hyder Individual W-2 Managing EmployeeAdministrator Mar 1, 2023
Operational/Managerial ControlAdministrator Mar 1, 2023
Providence Group NH, LLC Organization, Farmington, UT LLC, Holding company, For-profit 5% Or Greater Direct Ownership Interest Jun 30, 2023 100%
Pacs Holdings, LLC Organization, Farmington, UT LLC, Holding company 5% Or Greater Indirect Ownership Interest Jun 30, 2023 100%
Joshua O Jergensen Individual Corporate OfficerPresident Jan 1, 2024
Pacs Group, Inc. Organization, Farmington, UT Corporation, Holding company, For-profit 5% Or Greater Indirect Ownership Interest Jun 30, 2023 100%
Mark D Hancock Individual 5% Or Greater Indirect Ownership Interest Apr 15, 2024 41.8%
Corporate OfficerCeo Jan 1, 2024

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 186

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 186

Practitioners & affiliated clinicians

Affiliated clinicians 6

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1657497600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724025600000",
    "number": "1639803182",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "262 N UNIVERSITY AVE",
            "city": "FARMINGTON",
            "state": "UT",
            "postal_code": "840252975"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "619 N FAIRFAX AVE",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900361714",
            "telephone_number": "323-651-0043"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAIRFAX HEALTHCARE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-07-11",
        "last_updated": "2024-08-19",
        "certification_date": "2024-08-19",
        "status": "A",
        "authorized_official_last_name": "MITCHELL",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "SECRETARY",
        "authorized_official_telephone_number": "385-988-3319"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Kennedy Care Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Kennedy Care Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Los Angeles, CA

Sources for this page

Verify at the official NPI Registry.