Provider Demographics
NPI:1164435111
Name:FAIRPORT BAPTIST HOMES
Entity Type:Organization
Organization Name:FAIRPORT BAPTIST HOMES
Other - Org Name:LIFETIMES ADULT DAY HEALTH CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:POELMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-388-2300
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:
Mailing Address - Fax:
Practice Address - Street 1:4646 NINE MILE POINT RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1163
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:2006-08-14
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2725300N314000000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
105934CIOtherPREFERRED CARE
105934FQOtherPREFERRED CARE 'B'
P015005960OtherEXCELLUS BC/BS
NY00395657Medicaid
NY01703382Medicaid
NY01703382Medicaid
105934CIOtherPREFERRED CARE