Healthcare Provider Details

I. General information

NPI: 1669469854
Provider Name (Legal Business Name): KMJ ENTERPRISES HOMESTEAD 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

826 NORTH ST
STAMPS AR
71860-4522
US

IV. Provider business mailing address

826 NORTH ST
STAMPS AR
71860-4522
US

V. Phone/Fax

Practice location:
  • Phone: 870-533-4444
  • Fax: 870-533-8841
Mailing address:
  • Phone: 870-533-4444
  • Fax: 870-533-8841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number715
License Number StateAR

VIII. Authorized Official

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