Healthcare Provider Details

I. General information

NPI: 1093935967
Provider Name (Legal Business Name): INDEPENDENT LIVING FOR SENIORS - FEE FOR SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2066 HUDSON AVE
ROCHESTER NY
14617-4300
US

IV. Provider business mailing address

2066 HUDSON AVE
ROCHESTER NY
14617-4300
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-2800
  • Fax:
Mailing address:
  • Phone: 585-922-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN P MIDOLO
Title or Position: VP-PATIENT FINANCIAL SERVICES
Credential:
Phone: 585-922-1958