Healthcare Provider Details

I. General information

NPI: 1780924191
Provider Name (Legal Business Name): VK KENNEBUNK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 ROSS RD
KENNEBUNK ME
04043-6532
US

IV. Provider business mailing address

46 STAUDERMAN AVE
LYNBROOK NY
11563-2524
US

V. Phone/Fax

Practice location:
  • Phone: 207-985-7141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1780924191
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name: MR. BARRY BOKOW
Title or Position: VICE PRESIDENT
Credential:
Phone: 516-705-4802