Healthcare Provider Details

I. General information

NPI: 1962846709
Provider Name (Legal Business Name): KC PBG HEALTH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 MASTERPIECE WAY
PALM BEACH GARDENS FL
33410-2872
US

IV. Provider business mailing address

5790 FLEET ST SUITE 300
CARLSBAD CA
92008-4703
US

V. Phone/Fax

Practice location:
  • Phone: 561-514-5000
  • Fax:
Mailing address:
  • Phone: 760-804-5900
  • Fax: 760-804-5909

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: ANDREW SCOTT KOHLBERG
Title or Position: PRESIDENT
Credential:
Phone: 760-804-5900