Provider Demographics
NPI:1174122758
Name:KMJV OPERATION LLC
Entity type:Organization
Organization Name:KMJV OPERATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:R
Authorized Official - Last Name:MATTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-658-2165
Mailing Address - Street 1:6404 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19351 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-4849
Practice Address - Country:US
Practice Address - Phone:952-206-4650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging