Healthcare Provider Details

I. General information

NPI: 1497973382
Provider Name (Legal Business Name): JACQUELINE KILGORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 ALPHA ST
CAMDEN AR
71701-3000
US

IV. Provider business mailing address

365 ALPHA ST
CAMDEN AR
71701-3000
US

V. Phone/Fax

Practice location:
  • Phone: 870-836-9337
  • Fax: 870-836-5606
Mailing address:
  • Phone: 870-836-9337
  • Fax: 870-836-5606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number655
License Number StateAR

VIII. Authorized Official

Name: AVON MITCHELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 501-332-6934