Provider Demographics
NPI:1013396209
Name:KJG LLC
Entity Type:Organization
Organization Name:KJG LLC
Other - Org Name:FAMILY LIFE CHIROPRACTIC & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:785-883-9355
Mailing Address - Street 1:430 MAIN ST
Mailing Address - Street 2:PO BOX 726
Mailing Address - City:WELLSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66092-8878
Mailing Address - Country:US
Mailing Address - Phone:785-883-9355
Mailing Address - Fax:785-883-4030
Practice Address - Street 1:430 MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66092-0726
Practice Address - Country:US
Practice Address - Phone:785-883-9355
Practice Address - Fax:785-883-4030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-21
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0105260111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1851548309OtherNPPES