Provider Demographics
NPI:1144279712
Name:SENIOR RESIDENTIAL CARE - KINGSTON, INC.
Entity type:Organization
Organization Name:SENIOR RESIDENTIAL CARE - KINGSTON, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMILYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:781-707-9510
Mailing Address - Street 1:63 KENDRICK ST
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-2708
Mailing Address - Country:US
Mailing Address - Phone:781-707-9085
Mailing Address - Fax:781-707-9285
Practice Address - Street 1:17 CHIPMAN WAY
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:MA
Practice Address - Zip Code:02364-1039
Practice Address - Country:US
Practice Address - Phone:781-585-4100
Practice Address - Fax:781-585-1651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA310400000X
MA0931314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1906119Medicaid
MA110026630CMedicaid
MA0928160Medicaid
MA110026630AMedicaid
MA110026630AMedicaid