Provider Demographics
NPI:1811992944
Name:WEDGEWOOD NURSING HOME, INC.
Entity type:Organization
Organization Name:WEDGEWOOD NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:MART
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:585-244-1374
Practice Address - Street 1:5 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1343
Practice Address - Country:US
Practice Address - Phone:585-352-4810
Practice Address - Fax:585-352-1032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2722301314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00474442Medicaid
NY335408Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER