MEDICARE: KMJ ENTERPRISES FIANNA HILLS 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	314000000X	Skilled Nursing Facility	724	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710974274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KMJ ENTERPRISES FIANNA HILLS LLC

Provider Business Mailing Address
First Line	:	8411 S 28TH ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-8646
Country	:	US
Telephone Number	:	479-648-9600
Fax Number	:	479-648-9673

Provider Business Practice Location Address
First Line	:	8411 S 28TH ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-8646
Country	:	US
Telephone Number	:	479-648-9600
Fax Number	:	479-648-9673

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MICHAEL C HATHORN
Credential	:
Telephone Number	:	479-636-5716

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	04/18/2024

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