Provider Demographics
NPI:1003431438
Name:KJ ADULT CARE ,LLC
Entity Type:Organization
Organization Name:KJ ADULT CARE ,LLC
Other - Org Name:KJ ADULT CARE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:CHISLOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-557-2613
Mailing Address - Street 1:1002 W SOLOMON ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-2632
Mailing Address - Country:US
Mailing Address - Phone:678-557-2613
Mailing Address - Fax:678-572-4514
Practice Address - Street 1:1002 W SOLOMON ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-2632
Practice Address - Country:US
Practice Address - Phone:678-557-2613
Practice Address - Fax:678-572-4514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1801354774Medicaid