Healthcare Provider Details

I. General information

NPI: 1003431438
Provider Name (Legal Business Name): KJ ADULT CARE ,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 W SOLOMON ST
GRIFFIN GA
30223-2632
US

IV. Provider business mailing address

1002 W SOLOMON ST
GRIFFIN GA
30223-2632
US

V. Phone/Fax

Practice location:
  • Phone: 678-557-2613
  • Fax: 678-572-4514
Mailing address:
  • Phone: 678-557-2613
  • Fax: 678-572-4514

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: TRACIE RENEE CHISLOM
Title or Position: OWNER
Credential:
Phone: 678-557-2613