Provider Demographics
NPI:1316778780
Name:KINGSTON RESIDENCE OF FORT WAYNE, LLC
Entity type:Organization
Organization Name:KINGSTON RESIDENCE OF FORT WAYNE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-392-8529
Mailing Address - Street 1:1 SEAGATE STE 1960
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1592
Mailing Address - Country:US
Mailing Address - Phone:419-725-1938
Mailing Address - Fax:419-247-2872
Practice Address - Street 1:7515 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46819-2257
Practice Address - Country:US
Practice Address - Phone:260-747-1523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility