Provider Demographics
NPI:1124080221
Name:KDM INC
Entity type:Organization
Organization Name:KDM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-257-6761
Mailing Address - Street 1:55 NURSING HOME RD
Mailing Address - Street 2:
Mailing Address - City:CHUCKEY
Mailing Address - State:TN
Mailing Address - Zip Code:37641
Mailing Address - Country:US
Mailing Address - Phone:423-257-6761
Mailing Address - Fax:423-257-4936
Practice Address - Street 1:55 NURSING HOME RD
Practice Address - Street 2:
Practice Address - City:CHUCKEY
Practice Address - State:TN
Practice Address - Zip Code:37641
Practice Address - Country:US
Practice Address - Phone:423-257-6761
Practice Address - Fax:423-257-4936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000310313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440366Medicaid
TN0445478Medicaid
445478Medicare Oscar/Certification
5241050001Medicare NSC