MEDICARE: KELLOGG BEACH HOLDINGS 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1962239590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLOGG BEACH HOLDINGS LLC

Provider Business Mailing Address
First Line	:	16544 FRANZEN FARM RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92127-2240
Country	:	US
Telephone Number	:	858-798-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	1025 W 2ND AVE
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92025-3839
Country	:	US
Telephone Number	:	760-745-1842
Fax Number	:

Authorized Official
Title or Position	:	CO-CEO
Name	:	TOBY TILFORD
Credential	:
Telephone Number	:	858-774-8342

Provider Enumeration Date	:	09/17/2024
Last Update Date	:	11/15/2024

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