Provider Demographics
NPI:1093935967
Name:INDEPENDENT LIVING FOR SENIORS - FEE FOR SERVICE
Entity Type:Organization
Organization Name:INDEPENDENT LIVING FOR SENIORS - FEE FOR SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP-PATIENT FINANCIAL SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MIDOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-922-1958
Mailing Address - Street 1:2066 HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-4300
Mailing Address - Country:US
Mailing Address - Phone:585-922-2800
Mailing Address - Fax:
Practice Address - Street 1:2066 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14617-4300
Practice Address - Country:US
Practice Address - Phone:585-922-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00303315Medicaid