Provider Demographics
NPI:1972500692
Name:KKJ ENTERPRISES, INC
Entity Type:Organization
Organization Name:KKJ ENTERPRISES, INC
Other - Org Name:CRYSTAL CARE CENTER OF PORTSMOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:SAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-354-6619
Mailing Address - Street 1:PO BOX 439
Mailing Address - Street 2:1319 SPRING STREET
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662
Mailing Address - Country:US
Mailing Address - Phone:740-354-6619
Mailing Address - Fax:740-353-6770
Practice Address - Street 1:1319 SPRING STREET
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662
Practice Address - Country:US
Practice Address - Phone:740-354-6619
Practice Address - Fax:740-354-5710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
OH314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2335155Medicaid
OH134209136OtherINSURANCE COMPANIES
OH0060574Medicaid
OH365867Medicare Oscar/Certification