Healthcare Provider Details

I. General information

NPI: 1295461036
Provider Name (Legal Business Name): KBS MEDICAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 SW 148TH AVE STE 110
MIRAMAR FL
33027-3237
US

IV. Provider business mailing address

169 MADISON AVE STE 15824
NEW YORK NY
10016-5101
US

V. Phone/Fax

Practice location:
  • Phone: 847-420-5269
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LISA KENNEDY
Title or Position: COO
Credential:
Phone: 212-620-3053