MEDICARE: MEMPHIS KG PROPERTY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	ACL0000000131	TN

General Provider Information

NPI Number	:	1952548125
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMPHIS KG PROPERTY, LLC

Provider Business Mailing Address
First Line	:	3723 FAIRVIEW INDUSTRIAL DR SE
Second Line	:	SUITE 270
City	:	SALEM
State	:	OR
Zip	:	97302-1177
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6480 QUINCE RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-8222
Country	:	US
Telephone Number	:	901-753-3449
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JON HARDER
Credential	:
Telephone Number	:	503-375-9016

Provider Enumeration Date	:	01/09/2009
Last Update Date	:	01/09/2009

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Directions to “MEMPHIS KG PROPERTY, LLC ” Practice Location

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