Provider Demographics
NPI:1447212915
Name:KING STREET HOME INC
Entity Type:Organization
Organization Name:KING STREET HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-937-5800
Mailing Address - Street 1:787 KING ST
Mailing Address - Street 2:
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-1225
Mailing Address - Country:US
Mailing Address - Phone:914-937-5800
Mailing Address - Fax:914-949-6986
Practice Address - Street 1:787 KING ST
Practice Address - Street 2:
Practice Address - City:RYE BROOK
Practice Address - State:NY
Practice Address - Zip Code:10573-1225
Practice Address - Country:US
Practice Address - Phone:914-937-5800
Practice Address - Fax:914-949-6986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5906300N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00312978Medicaid
NY335447Medicare PIN