Provider Demographics
NPI:1275154262
Name:KTJ 292, LLC
Entity Type:Organization
Organization Name:KTJ 292, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLLIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-623-7000
Mailing Address - Street 1:22 MALCOLM AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-7584
Mailing Address - Country:US
Mailing Address - Phone:612-723-7000
Mailing Address - Fax:
Practice Address - Street 1:22 MALCOLM AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-7584
Practice Address - Country:US
Practice Address - Phone:612-723-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility