Provider Demographics
NPI:1255489183
Name:PARK RIDGE NURSING HOME
Entity Type:Organization
Organization Name:PARK RIDGE NURSING HOME
Other - Org Name:PRNH NON-OCCUPANT ADC MSAC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP ELDERONE
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAZIANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-922-2808
Mailing Address - Street 1:2300 BUFFALO RD
Mailing Address - Street 2:BUILDING 600B
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-1360
Mailing Address - Country:US
Mailing Address - Phone:585-368-6470
Mailing Address - Fax:585-368-6471
Practice Address - Street 1:2300 BUFFALO RD
Practice Address - Street 2:BUILDING 600B
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-1360
Practice Address - Country:US
Practice Address - Phone:585-368-6470
Practice Address - Fax:585-368-6471
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK RIDGE LIVING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-08
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01186429Medicaid