Healthcare Provider Details

I. General information

NPI: 1497958987
Provider Name (Legal Business Name): ST. JOHN'S NURSING HOME NON OCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 HIGHLAND AVE
ROCHESTER NY
14620-3024
US

IV. Provider business mailing address

150 HIGHLAND AVE
ROCHESTER NY
14620-3024
US

V. Phone/Fax

Practice location:
  • Phone: 585-271-5413
  • Fax: 585-760-1497
Mailing address:
  • Phone: 585-271-5413
  • Fax: 585-760-1497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES RUNYON
Title or Position: CEO, PRESIDENT
Credential:
Phone: 585-760-1202