Healthcare Provider Details

I. General information

NPI: 1649266636
Provider Name (Legal Business Name): KIOSK INC, DBA HAVENWOOD REST HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 WALNUT ST
NEW BEDFORD MA
02740-4964
US

IV. Provider business mailing address

251 WALNUT ST
NEW BEDFORD MA
02740-4964
US

V. Phone/Fax

Practice location:
  • Phone: 508-994-3120
  • Fax:
Mailing address:
  • Phone: 508-994-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number5507219
License Number StateMA

VIII. Authorized Official

Name: MR. DONALD LEO DISANTI
Title or Position: PRESIDENT
Credential:
Phone: 508-994-3120