Provider Demographics
NPI:1871580076
Name:KMJ ENTERPRISES MOUNTAIN HOME LLC
Entity type:Organization
Organization Name:KMJ ENTERPRISES MOUNTAIN HOME 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 1:1100 PINE TREE LN
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-4502
Mailing Address - Country:US
Mailing Address - Phone:870-425-6316
Mailing Address - Fax:870-424-5197
Practice Address - Street 1:1100 PINE TREE LN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-4502
Practice Address - Country:US
Practice Address - Phone:870-425-6316
Practice Address - Fax:870-424-5197
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KMJ MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-03
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR720314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119728311Medicaid
AR045163Medicare Oscar/Certification