Basic Information
Provider Information | |||||||||
NPI: | 1255388443 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KENSINGTON MANOR - SARASOTA FL LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROMEDICA SKILLED NURSING AND REHABILITATION (SARASOTA NORTH) | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 333 N SUMMIT ST | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436042615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192525500 | ||||||||
FaxNumber: | 8773859446 | ||||||||
Practice Location | |||||||||
Address1: | 3250 12TH ST | ||||||||
Address2: |   | ||||||||
City: | SARASOTA | ||||||||
State: | FL | ||||||||
PostalCode: | 342373204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9413654185 | ||||||||
FaxNumber: | 9413654465 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2006 | ||||||||
LastUpdateDate: | 01/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALLEN | ||||||||
AuthorizedOfficialFirstName: | MARTIN | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4192525734 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF12640961 | FL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 032549000 | 05 | FL |   | MEDICAID |