Provider Demographics
NPI:1194893719
Name:KENNETH GAUL II, LLC
Entity type:Organization
Organization Name:KENNETH GAUL II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MADELINE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:631-878-4400
Mailing Address - Street 1:6 FROWEIN RD
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934-1604
Mailing Address - Country:US
Mailing Address - Phone:631-878-4400
Mailing Address - Fax:631-878-6865
Practice Address - Street 1:6 FROWEIN RD
Practice Address - Street 2:
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934-1604
Practice Address - Country:US
Practice Address - Phone:631-878-4400
Practice Address - Fax:631-878-6865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5151313N313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00311399Medicaid
NY335402Medicare Oscar/Certification