Healthcare Provider Details

I. General information

NPI: 1568466076
Provider Name (Legal Business Name): KJD INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 S BROADWAY
SAINT LOUIS MO
63111-2025
US

IV. Provider business mailing address

5500 S BROADWAY
SAINT LOUIS MO
63111-2025
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-5900
  • Fax: 314-353-5907
Mailing address:
  • Phone: 314-353-5900
  • Fax: 314-353-5907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number031300
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031299
License Number StateMO

VIII. Authorized Official

Name: MR. DEAN DAIGGER
Title or Position: ADMINISTRATOR
Credential:
Phone: 314-353-5900