Healthcare Provider Details

I. General information

NPI: 1871500983
Provider Name (Legal Business Name): KSJ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MANOR RD
PRESCOTT AR
71857-2800
US

IV. Provider business mailing address

700 MANOR RD
PRESCOTT AR
71857-2800
US

V. Phone/Fax

Practice location:
  • Phone: 870-887-6639
  • Fax: 870-887-6690
Mailing address:
  • Phone: 870-887-6639
  • Fax: 870-887-6690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0613
License Number StateAR

VIII. Authorized Official

Name: KEITH HEAD
Title or Position: MANAGING PARTNER
Credential:
Phone: 870-887-6639