Healthcare Provider Details

I. General information

NPI: 1124449632
Provider Name (Legal Business Name): KMJ ENTERPRISES BENTON II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2013
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6907 HIGHWAY 5 N
BRYANT AR
72022-7902
US

IV. Provider business mailing address

6907 HIGHWAY 5 N
BRYANT AR
72022-7902
US

V. Phone/Fax

Practice location:
  • Phone: 501-213-0547
  • Fax: 501-213-0553
Mailing address:
  • Phone: 501-213-0547
  • Fax: 501-213-0553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number711
License Number StateAR

VIII. Authorized Official

Name: DON SCHAAP
Title or Position: CEO
Credential:
Phone: 479-636-5716