Provider Demographics
NPI:1871580050
Name:KMJ ENTERPRISES BENTON II LLC
Entity type:Organization
Organization Name:KMJ ENTERPRISES BENTON II LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-636-5716
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-0280
Mailing Address - Country:US
Mailing Address - Phone:501-778-7417
Mailing Address - Fax:501-778-4471
Practice Address - Street 1:809 KENWOOD RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2337
Practice Address - Country:US
Practice Address - Phone:501-778-7417
Practice Address - Fax:501-778-4471
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KMJ MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-03
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR711314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119719311Medicaid
AR119719311Medicaid