Provider Demographics
NPI:1124449632
Name:KMJ ENTERPRISES BENTON II, LLC
Entity type:Organization
Organization Name:KMJ ENTERPRISES BENTON II, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHAAP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-636-5716
Mailing Address - Street 1:6907 HIGHWAY 5 N
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-7902
Mailing Address - Country:US
Mailing Address - Phone:501-213-0547
Mailing Address - Fax:501-213-0553
Practice Address - Street 1:6907 HIGHWAY 5 N
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-7902
Practice Address - Country:US
Practice Address - Phone:501-213-0547
Practice Address - Fax:501-213-0553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR711314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200762311Medicaid
AR045457Medicare Oscar/Certification