Provider Demographics
NPI:1134457849
Name:FAIRPORT BAPTIST HOME ADHC
Entity Type:Organization
Organization Name:FAIRPORT BAPTIST HOME ADHC
Other - Org Name:LIFETIMES ADULT DAY CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOYTASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-388-2303
Mailing Address - Street 1:4646 NINE MILE POINT RD
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1163
Mailing Address - Country:US
Mailing Address - Phone:585-388-2303
Mailing Address - Fax:585-377-2620
Practice Address - Street 1:14001 S PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611
Practice Address - Country:US
Practice Address - Phone:585-388-2303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01703382Medicaid