Healthcare Provider Details

I. General information

NPI: 1164061628
Provider Name (Legal Business Name): IBERO AMERICAN ACTION LUEAGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 EAST MAIN STREET SAME
ROCHESTER NY
14605-5144
US

IV. Provider business mailing address

817 EAST MAIN STREET SAME
ROCHESTER NY
14605-5144
US

V. Phone/Fax

Practice location:
  • Phone: 585-256-8900
  • Fax: 585-544-8608
Mailing address:
  • Phone: 585-256-8900
  • Fax: 585-544-8608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MS. GRISELL MARIN
Title or Position: HCBS DIRECTOR
Credential: BS, CASAC- T
Phone: 585-256-8900