=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619964160
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KMJ ENTERPRISES BENTONVILLE MANOR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2005
-----------------------------------------------------
Last Update Date | 06/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 S MAIN ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-5963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-273-3373
-----------------------------------------------------
Fax | 479-273-0623
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224 S MAIN ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-5963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-273-3373
-----------------------------------------------------
Fax | 479-273-0623
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MS. PATRICIA MILLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-636-5716
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 712
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------