Healthcare Provider Details

I. General information

NPI: 1124080221
Provider Name (Legal Business Name): KDM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 NURSING HOME RD
CHUCKEY TN
37641
US

IV. Provider business mailing address

55 NURSING HOME RD
CHUCKEY TN
37641
US

V. Phone/Fax

Practice location:
  • Phone: 423-257-6761
  • Fax: 423-257-4936
Mailing address:
  • Phone: 423-257-6761
  • Fax: 423-257-4936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0000000310
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0000000310
License Number StateTN

VIII. Authorized Official

Name: KATHIE H BALL
Title or Position: PRESIDENT
Credential:
Phone: 423-257-6761