Provider Demographics
NPI:1518015841
Name:PARK RIDGE NURSING HOME, INC
Entity Type:Organization
Organization Name:PARK RIDGE NURSING HOME, INC
Other - Org Name:PARK RIDGE AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP HOME ANDCOMMUNITY BASED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-368-6454
Mailing Address - Street 1:89 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14611-3201
Mailing Address - Country:US
Mailing Address - Phone:585-368-6342
Mailing Address - Fax:585-368-6395
Practice Address - Street 1:89 GENESEE ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-3201
Practice Address - Country:US
Practice Address - Phone:585-368-6342
Practice Address - Fax:585-368-6395
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK RIDGE NURSING HOME, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-05
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01185955Medicaid
NY109058C1OtherPREFERRED CARE
NYP0101059PROtherBLUE CHOICE
NY109058C1OtherPREFERRED CARE
NY337267Medicare Oscar/Certification