=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457359432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOYD'S KINSMAN HOME, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7929 STATE ROUTE #5
-----------------------------------------------------
City | KINSMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44428-0315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-876-5581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 315 7929 STATE ROUTE #5
-----------------------------------------------------
City | KINSMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44428-0315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 330-876-8804
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSING HOME ADMINISTRATOR
-----------------------------------------------------
Name | MRS. PAULA L. RUBY
-----------------------------------------------------
Credential | LNHA, QMRP
-----------------------------------------------------
Telephone | 330-876-5581
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | 7810042
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------