1013396209 NPI number — KJG LLC

Table of content: (NPI 1013396209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013396209 NPI number — KJG LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KJG LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013396209
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 726
Provider Business Mailing Address City Name:
WELLSVILLE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66092-8878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-883-9355
Provider Business Mailing Address Fax Number:
785-883-4030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELLSVILLE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66092-0726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-883-9355
Provider Business Practice Location Address Fax Number:
785-883-4030
Provider Enumeration Date:
05/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GIBBONS
Authorized Official First Name:
KRISTINA
Authorized Official Middle Name:
JEANNE
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
785-883-9355

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  0105260 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1851548309 . This is a "NPPES" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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