Healthcare Provider Details

I. General information

NPI: 1376580266
Provider Name (Legal Business Name): KIMWELL HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 NEW BOSTON RD
FALL RIVER MA
02720-5835
US

IV. Provider business mailing address

495 NEW BOSTON RD
FALL RIVER MA
02720-5835
US

V. Phone/Fax

Practice location:
  • Phone: 508-679-0106
  • Fax: 508-674-1570
Mailing address:
  • Phone: 508-679-0106
  • Fax: 508-674-1570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0720
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier110026658B
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
Identifier0940542
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: JOHN G. FREDETTE
Title or Position: MANAGER
Credential:
Phone: 508-679-0106