Provider Demographics
NPI:1023186723
Name:KSJR HEALTHCARE, LLC
Entity Type:Organization
Organization Name:KSJR HEALTHCARE, LLC
Other - Org Name:QUAPAW QUARTER NURSING CENTER & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-374-7565
Mailing Address - Street 1:1516 CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-5065
Mailing Address - Country:US
Mailing Address - Phone:501-374-7565
Mailing Address - Fax:501-372-8026
Practice Address - Street 1:1516 CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-5065
Practice Address - Country:US
Practice Address - Phone:501-374-7565
Practice Address - Fax:501-372-8026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR726314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119734311Medicaid
AR045359Medicare ID - Type UnspecifiedPROVIDER NUMBER