1134457849 NPI number — FAIRPORT BAPTIST HOME ADHC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134457849 NPI number — FAIRPORT BAPTIST HOME ADHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRPORT BAPTIST HOME ADHC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134457849
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4646 NINE MILE POINT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRPORT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14450-1163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-388-2303
Provider Business Mailing Address Fax Number:
585-377-2620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14001 S PLYMOUTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-388-2303
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WOYTASH
Authorized Official First Name:
GERARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
VICE PRESIDENT OF FINANCE
Authorized Official Telephone Number:
585-388-2303

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01703382 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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