Provider Demographics
NPI:1275538407
Name:PENFIELD PLACE, LLC
Entity Type:Organization
Organization Name:PENFIELD PLACE, LLC
Other - Org Name:PENFIELD PLACE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:HURLBUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-244-0410
Mailing Address - Street 1:740 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-2107
Mailing Address - Country:US
Mailing Address - Phone:585-244-0410
Mailing Address - Fax:585-244-1208
Practice Address - Street 1:1700 PENFIELD RD
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-2108
Practice Address - Country:US
Practice Address - Phone:585-586-7433
Practice Address - Fax:585-586-7799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2761300314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00922918Medicaid
NY00922918Medicaid