Healthcare Provider Details

I. General information

NPI: 1356338594
Provider Name (Legal Business Name): KINGSTON OF VERMILION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 TELEGRAPH LN
VERMILION OH
44089-3748
US

IV. Provider business mailing address

PO BOX 2165
TOLEDO OH
43603-2165
US

V. Phone/Fax

Practice location:
  • Phone: 440-967-1800
  • Fax: 440-967-0122
Mailing address:
  • Phone: 419-247-2880
  • Fax: 419-247-2872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1806N
License Number StateOH

VIII. Authorized Official

Name: MR. LARRY NIRSCHL
Title or Position: TREASURER
Credential:
Phone: 419-247-2824