=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770675571
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | K.J.,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 736 HEYLMAN ST
-----------------------------------------------------
City | FORT SCOTT
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66701-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-223-3120
-----------------------------------------------------
Fax | 620-223-3884
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 831
-----------------------------------------------------
City | FORT SCOTT
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66701-0831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-223-3120
-----------------------------------------------------
Fax | 620-223-3884
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/CEO
-----------------------------------------------------
Name | MR. WILLIAM R FISCHER
-----------------------------------------------------
Credential | LNHA
-----------------------------------------------------
Telephone | 620-223-3120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | N006004
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------