Healthcare Provider Details

I. General information

NPI: 1164435111
Provider Name (Legal Business Name): FAIRPORT BAPTIST HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 NINE MILE POINT RD
FAIRPORT NY
14450-1163
US

IV. Provider business mailing address

4646 NINE MILE POINT RD
FAIRPORT NY
14450-1163
US

V. Phone/Fax

Practice location:
  • Phone: 585-388-2303
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2725300N
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS H. POELMA
Title or Position: PRESIDENT/CEO
Credential:
Phone: 585-388-2300