Provider Demographics
NPI:1972590115
Name:KINGSTON OF MIAMISBURG, LLC
Entity Type:Organization
Organization Name:KINGSTON OF MIAMISBURG, LLC
Other - Org Name:KINGSTON OF MIAMISBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:NIRSCHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-247-2824
Mailing Address - Street 1:PO BOX 2165
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43603-2165
Mailing Address - Country:US
Mailing Address - Phone:419-247-2880
Mailing Address - Fax:419-247-2872
Practice Address - Street 1:1120 DUNAWAY ST
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-3839
Practice Address - Country:US
Practice Address - Phone:937-866-9089
Practice Address - Fax:937-866-6907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1613N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000003059OtherANTHEM BC/BS
OH2611212Medicaid
OH=========Medicare UPIN
OH000000003059OtherANTHEM BC/BS