Provider Demographics
NPI:1619400199
Name:KTJ 270 LLC
Entity Type:Organization
Organization Name:KTJ 270 LLC
Other - Org Name:WHITE BEAR HEIGHTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-653-3288
Mailing Address - Street 1:4650 CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55127-2301
Mailing Address - Country:US
Mailing Address - Phone:651-653-3288
Mailing Address - Fax:
Practice Address - Street 1:4650 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55127-2301
Practice Address - Country:US
Practice Address - Phone:651-653-3288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32991310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility