Healthcare Provider Details

I. General information

NPI: 1578193801
Provider Name (Legal Business Name): JMK RESIDENTIAL FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2020
Last Update Date: 01/26/2020
Certification Date: 01/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1278 E 125TH ST
LOS ANGELES CA
90059-3216
US

IV. Provider business mailing address

1278 E 125TH ST
LOS ANGELES CA
90059-3216
US

V. Phone/Fax

Practice location:
  • Phone: 310-756-3839
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEANETTE M KIDD
Title or Position: SECRETARY
Credential:
Phone: 310-756-3839