Provider Demographics
NPI:1750735361
Name:PARK RIDGE NURSING HOME
Entity type:Organization
Organization Name:PARK RIDGE NURSING HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT 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 1:1555 LONG POND RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4122
Mailing Address - Country:US
Mailing Address - Phone:585-723-7260
Mailing Address - Fax:585-723-7831
Practice Address - Street 1:1555 LONG POND RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4122
Practice Address - Country:US
Practice Address - Phone:585-723-7260
Practice Address - Fax:585-723-7831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2754302N261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01186429Medicaid