Provider Demographics
NPI:1124015680
Name:KMJ ENTERPRISES CLARKSVILLE LLC
Entity Type:Organization
Organization Name:KMJ ENTERPRISES CLARKSVILLE LLC
Other - Org Name:CLARKSVILLE CONVALESCENT HOME
Other - Org Type:Doing Business As
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 1:400 OAK CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-3778
Mailing Address - Country:US
Mailing Address - Phone:479-754-8611
Mailing Address - Fax:479-754-2369
Practice Address - Street 1:400 OAK CT
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-3778
Practice Address - Country:US
Practice Address - Phone:479-754-8611
Practice Address - Fax:479-754-2369
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KMJ MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-30
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR702314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119715311Medicaid
AR119715311Medicaid