Provider Demographics
NPI:1811044522
Name:NORTH PARK NURSING HOME, INC.
Entity Type:Organization
Organization Name:NORTH PARK NURSING HOME, INC.
Other - Org Name:EDNA TINA WILSON LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR , NHA
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TEUGEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-368-6105
Mailing Address - Street 1:700 ISLAND COTTAGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-2312
Mailing Address - Country:US
Mailing Address - Phone:585-368-6100
Mailing Address - Fax:585-368-6110
Practice Address - Street 1:700 ISLAND COTTAGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-2312
Practice Address - Country:US
Practice Address - Phone:585-368-6100
Practice Address - Fax:585-368-6110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01447869Medicaid
NYNH620OtherPREFERRED CARE
NY0150059ETOtherBLUE SHIELD BLUE CHOICE
NY70008AMedicare PIN
NYNH620OtherPREFERRED CARE