Provider Demographics
NPI:1568434629
Name:KINGDOM REHAB CENTER, LLC
Entity Type:Organization
Organization Name:KINGDOM REHAB CENTER, LLC
Other - Org Name:MAPLE LANE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHENEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:802-626-3890
Mailing Address - Street 1:601B RED VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05851-9068
Mailing Address - Country:US
Mailing Address - Phone:802-626-3890
Mailing Address - Fax:802-626-0983
Practice Address - Street 1:60 MAPLE LN
Practice Address - Street 2:
Practice Address - City:BARTON
Practice Address - State:VT
Practice Address - Zip Code:05822-9494
Practice Address - Country:US
Practice Address - Phone:802-626-3890
Practice Address - Fax:802-626-0983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0475042Medicaid
VT475042AMedicare ID - Type UnspecifiedMEDICARD PROVIDER NUMBER