Provider Demographics
NPI:1669469854
Name:KMJ ENTERPRISES HOMESTEAD LLC
Entity Type:Organization
Organization Name:KMJ ENTERPRISES HOMESTEAD LLC
Other - Org Name:HOMESTEAD MANOR NURSING 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 1:826 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:STAMPS
Mailing Address - State:AR
Mailing Address - Zip Code:71860-4522
Mailing Address - Country:US
Mailing Address - Phone:870-533-4444
Mailing Address - Fax:870-533-8841
Practice Address - Street 1:826 NORTH ST
Practice Address - Street 2:
Practice Address - City:STAMPS
Practice Address - State:AR
Practice Address - Zip Code:71860-4522
Practice Address - Country:US
Practice Address - Phone:870-533-4444
Practice Address - Fax:870-533-8841
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KMJ MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-03
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR715314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119723311Medicaid
AR119723311Medicaid