Provider Demographics
NPI:1093117657
Name:KLLG CORPORATION
Entity Type:Organization
Organization Name:KLLG CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-268-8699
Mailing Address - Street 1:PO BOX 408
Mailing Address - Street 2:
Mailing Address - City:CUTTEN
Mailing Address - State:CA
Mailing Address - Zip Code:95534-0408
Mailing Address - Country:US
Mailing Address - Phone:707-268-8699
Mailing Address - Fax:707-442-9274
Practice Address - Street 1:3231 DOLBEER ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-5631
Practice Address - Country:US
Practice Address - Phone:707-444-2076
Practice Address - Fax:707-444-2079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126803419310400000X
CA126803492310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility