Provider Demographics
NPI:1942272349
Name:KINGSBURY MEMORIAL MANOR
Entity Type:Organization
Organization Name:KINGSBURY MEMORIAL MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOWIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-888-2923
Mailing Address - Street 1:703 4TH ST SE
Mailing Address - Street 2:
Mailing Address - City:LAKE PRESTON
Mailing Address - State:SD
Mailing Address - Zip Code:57249-2116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:703 4TH ST SE
Practice Address - Street 2:
Practice Address - City:LAKE PRESTON
Practice Address - State:SD
Practice Address - Zip Code:57249-2116
Practice Address - Country:US
Practice Address - Phone:605-847-4405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10640314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD85067OtherWELLMARK
SD0151270Medicaid
SD0151270Medicaid