Healthcare Provider Details

I. General information

NPI: 1376530972
Provider Name (Legal Business Name): KINGSTON NURSING HOME LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 W 3RD ST
KINGSTON OH
45644
US

IV. Provider business mailing address

PO BOX 477
KINGSTON OH
45644-0477
US

V. Phone/Fax

Practice location:
  • Phone: 740-642-2503
  • Fax: 740-642-3656
Mailing address:
  • Phone: 740-642-2503
  • Fax: 740-642-3656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5322
License Number StateOH

VIII. Authorized Official

Name: MRS. TRACY R ROBERTSON
Title or Position: CORP. OFFICE EXECUTIVE ASSISTANT
Credential:
Phone: 419-526-0124