Provider Demographics
NPI:1487641841
Name:KMJ ENTERPRISES CASSVILLE LLC
Entity Type:Organization
Organization Name:KMJ ENTERPRISES CASSVILLE LLC
Other - Org Name:RED ROSE HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:ROSE HATHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-636-5716
Mailing Address - Street 1:7 HALSTED CIR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-3185
Mailing Address - Country:US
Mailing Address - Phone:479-636-5716
Mailing Address - Fax:479-636-2080
Practice Address - Street 1:812 OLD EXETER RD
Practice Address - Street 2:
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-1704
Practice Address - Country:US
Practice Address - Phone:417-847-2184
Practice Address - Fax:417-847-2642
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KMJ MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-30
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031016314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26A159Medicaid
MO26A159Medicaid