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General NPI Number Information
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NPI Number | 1174122758
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Entity Type | Organization
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Legal Business Name | KMJV OPERATION LLC
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Dates
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Enumeration Date | 10/23/2020
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Last Update Date | 10/23/2020
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Provider Practice Location Address
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Address Line | 19351 INDIANA AVE
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City | LAKEVILLE
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State | MN
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Zip | 55044-4849
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Country | US
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Telephone | 952-206-4650
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Fax |
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Provider Business Mailing Address
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Address Line | 6404 W NORTH AVE
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City | WAUWATOSA
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State | WI
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Zip | 53213
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | AARON R MATTER
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Credential |
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Telephone | 773-658-2165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 177F00000X
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Taxonomy Name | Lodging Provider
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License Number |
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License Number State |
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