Provider Demographics
NPI:1952590168
Name:JOHNSONVILLE HOME LLC
Entity type:Organization
Organization Name:JOHNSONVILLE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-371-3995
Mailing Address - Street 1:2419 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66104-4612
Mailing Address - Country:US
Mailing Address - Phone:913-371-3995
Mailing Address - Fax:866-372-9403
Practice Address - Street 1:2419 N 22ND ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66104-4612
Practice Address - Country:US
Practice Address - Phone:913-371-3995
Practice Address - Fax:866-372-9403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSB105114311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home