Provider Demographics
NPI:1730305798
Name:JACQUELINE KILGORE LLC
Entity Type:Organization
Organization Name:JACQUELINE KILGORE LLC
Other - Org Name:LONGMEADOW NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AVON
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-332-6934
Mailing Address - Street 1:P.O. BOX 566
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104
Mailing Address - Country:US
Mailing Address - Phone:501-332-6934
Mailing Address - Fax:501-332-6838
Practice Address - Street 1:912 SECTION LINE ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104
Practice Address - Country:US
Practice Address - Phone:501-332-6934
Practice Address - Fax:501-332-6838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR656314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility