MEDICARE: KG HOME CARE SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251T00000X	PACE Provider Organization	194700107	CA
2	253Z00000X	In Home Supportive Care Agency	194700107	CA

General Provider Information

NPI Number	:	1821540840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KG HOME CARE SERVICES LLC

Provider Business Mailing Address
First Line	:	8383 WILSHIRE BLVD
Second Line	:	STE 800
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-2425
Country	:	US
Telephone Number	:	323-561-5658
Fax Number	:	323-879-4282

Provider Business Practice Location Address
First Line	:	8383 WILSHIRE BLVD
Second Line	:	STE 800
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-2425
Country	:	US
Telephone Number	:	323-561-5658
Fax Number	:	323-879-4282

Authorized Official
Title or Position	:	CEO
Name	:	MR. KAMRAN GHASRI
Credential	:
Telephone Number	:	323-456-8645

Provider Enumeration Date	:	10/25/2016
Last Update Date	:	10/25/2016

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