Healthcare Provider Details

I. General information

NPI: 1871820076
Provider Name (Legal Business Name): CAYUGA RIDGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2009
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 TRUMANSBURG ROAD
ITHACA NY
14850-1313
US

IV. Provider business mailing address

1229 TRUMANSBURG ROAD
ITHACA NY
14850-1313
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-8072
  • Fax: 607-273-0373
Mailing address:
  • Phone: 607-273-8072
  • Fax: 607-273-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5401311N
License Number StateNY

VIII. Authorized Official

Name: MRS. BRENDA BAKER
Title or Position: ADMINISTRATOR
Credential:
Phone: 607-273-0373