Provider Demographics
NPI:1376580266
Name:KIMWELL HEALTHCARE LLC
Entity Type:Organization
Organization Name:KIMWELL HEALTHCARE LLC
Other - Org Name:KIMWELL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:FREDETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-679-0106
Mailing Address - Street 1:495 NEW BOSTON RD
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-5835
Mailing Address - Country:US
Mailing Address - Phone:508-679-0106
Mailing Address - Fax:508-674-1570
Practice Address - Street 1:495 NEW BOSTON RD
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5835
Practice Address - Country:US
Practice Address - Phone:508-679-0106
Practice Address - Fax:508-674-1570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0720314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026658BMedicaid
MA0940542Medicaid
MA0940542Medicaid