Provider Demographics
NPI:1134294978
Name:LOYOLA RECOVERY FOUNDATION, INC.
Entity Type:Organization
Organization Name:LOYOLA RECOVERY FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BASHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-203-1005
Mailing Address - Street 1:1159 PITTSFORD VICTOR RD
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-3808
Mailing Address - Country:US
Mailing Address - Phone:585-203-1005
Mailing Address - Fax:585-203-1013
Practice Address - Street 1:76 VETERANS AVE
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-0810
Practice Address - Country:US
Practice Address - Phone:607-664-5800
Practice Address - Fax:607-664-5801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00689721Medicaid