Healthcare Provider Details

I. General information

NPI: 1538156716
Provider Name (Legal Business Name): KMJ ENTERPRISES LITTLE ROCK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BROOKSIDE DR
LITTLE ROCK AR
72205-1644
US

IV. Provider business mailing address

800 BROOKSIDE DR
LITTLE ROCK AR
72205-1644
US

V. Phone/Fax

Practice location:
  • Phone: 501-224-3940
  • Fax: 501-224-6649
Mailing address:
  • Phone: 501-224-3940
  • Fax: 501-224-6649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number718
License Number StateAR

VIII. Authorized Official

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