Provider Demographics
NPI:1316488430
Name:PARK RIDGE NURSING HOME, INC.
Entity type:Organization
Organization Name:PARK RIDGE NURSING HOME, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT HOME CARE
Authorized Official - Prefix:MRS
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:585-368-4663
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:585-368-4663
Practice Address - Fax:585-368-6395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333300000XSuppliersEmergency Response System Companies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01396670Medicaid