Healthcare Provider Details

I. General information

NPI: 1942272349
Provider Name (Legal Business Name): KINGSBURY MEMORIAL MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 4TH ST SE
LAKE PRESTON SD
57249-2116
US

IV. Provider business mailing address

703 4TH ST SE
LAKE PRESTON SD
57249-2116
US

V. Phone/Fax

Practice location:
  • Phone: 605-847-4405
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10640
License Number StateSD

VIII. Authorized Official

Name: HOWIE GROFF
Title or Position: PRESIDENT
Credential:
Phone: 952-888-2923