Healthcare Provider Details

I. General information

NPI: 1962239590
Provider Name (Legal Business Name): KELLOGG BEACH HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 W 2ND AVE
ESCONDIDO CA
92025-3839
US

IV. Provider business mailing address

16544 FRANZEN FARM RD
SAN DIEGO CA
92127-2240
US

V. Phone/Fax

Practice location:
  • Phone: 760-745-1842
  • Fax:
Mailing address:
  • Phone: 858-798-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: TOBY TILFORD
Title or Position: CO-CEO
Credential:
Phone: 858-774-8342