Provider Demographics
NPI:1871500983
Name:KSJ, LLC
Entity Type:Organization
Organization Name:KSJ, LLC
Other - Org Name:PRESCOTT MANOR NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:HEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-887-6639
Mailing Address - Street 1:700 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71857-2800
Mailing Address - Country:US
Mailing Address - Phone:870-887-6639
Mailing Address - Fax:870-887-6690
Practice Address - Street 1:700 MANOR RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AR
Practice Address - Zip Code:71857-2800
Practice Address - Country:US
Practice Address - Phone:870-887-6639
Practice Address - Fax:870-887-6690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0613314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119673311Medicaid
AR119673311Medicaid