Healthcare Provider Details

I. General information

NPI: 1346976594
Provider Name (Legal Business Name): KINGSTON FALLS HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LILA DOYLE DR
SENECA SC
29672-9495
US

IV. Provider business mailing address

101 LILA DOYLE DR
SENECA SC
29672-9495
US

V. Phone/Fax

Practice location:
  • Phone: 864-885-7586
  • Fax: 864-885-7688
Mailing address:
  • Phone: 864-885-7586
  • Fax: 864-885-7688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SOON BURNAM
Title or Position: TREASURER
Credential:
Phone: 949-540-1249