MEDICARE: PARK RIDGE LIVING CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0600X	Adult Day Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023166378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK RIDGE LIVING CENTER

Provider Business Mailing Address
First Line	:	2260 LAKE AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14612-5758
Country	:	US
Telephone Number	:	585-254-8139
Fax Number	:

Provider Business Practice Location Address
First Line	:	2260 LAKE AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14612-5758
Country	:	US
Telephone Number	:	585-254-8139
Fax Number	:

Authorized Official
Title or Position	:	VP HOME AND COMMUNITY BASED SERVICE
Name	:	SUSAN BOURNE
Credential	:
Telephone Number	:	585-368-6454

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	01/14/2015

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Directions to “PARK RIDGE LIVING CENTER ” Practice Location

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