Provider Demographics
NPI:1649266636
Name:KIOSK INC, DBA HAVENWOOD REST HOME
Entity type:Organization
Organization Name:KIOSK INC, DBA HAVENWOOD REST HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:DISANTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-994-3120
Mailing Address - Street 1:251 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-4964
Mailing Address - Country:US
Mailing Address - Phone:508-994-3120
Mailing Address - Fax:
Practice Address - Street 1:251 WALNUT ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-4964
Practice Address - Country:US
Practice Address - Phone:508-994-3120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5507219311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5507219Medicaid