MEDICARE: KAL 2016, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1588121958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAL 2016, LLC

Provider Business Mailing Address
First Line	:	2103 CHANDLER ST
Second Line	:
City	:	KILGORE
State	:	TX
Zip	:	75662-3741
Country	:	US
Telephone Number	:	903-984-8839
Fax Number	:

Provider Business Practice Location Address
First Line	:	2103 CHANDLER ST
Second Line	:
City	:	KILGORE
State	:	TX
Zip	:	75662-3741
Country	:	US
Telephone Number	:	903-984-8839
Fax Number	:

Authorized Official
Title or Position	:	AVPO
Name	:	TANNER STIERWALT
Credential	:
Telephone Number	:	817-851-5805

Provider Enumeration Date	:	02/21/2019
Last Update Date	:	02/21/2019

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