=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528628922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHI-III KINGSTON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2019
-----------------------------------------------------
Last Update Date | 08/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 193 MAIN STREET ALL AMERICAN AT KINGSTON
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-347-5522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | C/O KAPLAN DEVELOPMENT GROUP 100 JERICHO QUADRANGLE, SUITE 142
-----------------------------------------------------
City | JERICHO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-496-1505
-----------------------------------------------------
Fax | 516-209-0019
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO/CFO
-----------------------------------------------------
Name | MR. RAYMOND DIOGUARDI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-496-1505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------