Provider Demographics
NPI:1619399136
Name:KMJC, LLC
Entity Type:Organization
Organization Name:KMJC, LLC
Other - Org Name:DELLWOOD GARDENS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-776-9511
Mailing Address - Street 1:753 7TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-5025
Mailing Address - Country:US
Mailing Address - Phone:651-776-9511
Mailing Address - Fax:
Practice Address - Street 1:753 7TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-5025
Practice Address - Country:US
Practice Address - Phone:651-776-9511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility