Healthcare Provider Details

I. General information

NPI: 1972590446
Provider Name (Legal Business Name): KMJ ENTERPRISES BENTON I LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 MILITARY RD
BENTON AR
72015-2581
US

IV. Provider business mailing address

3300 MILITARY RD
BENTON AR
72015-2581
US

V. Phone/Fax

Practice location:
  • Phone: 501-778-8282
  • Fax: 501-778-1232
Mailing address:
  • Phone: 501-778-8282
  • Fax: 501-778-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number709
License Number StateAR

VIII. Authorized Official

Name: PATRICIA MILLER
Title or Position: PRESIDENT/CEO
Credential:
Phone: 479-636-5716