Basic Information
| Provider Information | |||||||||
| NPI: | 1871500983 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KSJ, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PRESCOTT MANOR NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 MANOR RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718572800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708876639 | ||||||||
| FaxNumber: | 8708876690 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 MANOR RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718572800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708876639 | ||||||||
| FaxNumber: | 8708876690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEAD | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8708876639 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0613 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 119673311 | 05 | AR | MEDICAID |