Healthcare Provider Details

I. General information

NPI: 1548560733
Provider Name (Legal Business Name): PEMBROK HEALTH AND WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12133 PEMBROKE ROAD
PEMBROKE PINES FL
33025
US

IV. Provider business mailing address

12133 PEMBROKE ROAD
PEMBROKE PINES FL
33025
US

V. Phone/Fax

Practice location:
  • Phone: 954-499-4143
  • Fax: 954-499-4146
Mailing address:
  • Phone: 954-499-4143
  • Fax: 954-499-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberFLOS4139
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberFLOS4139
License Number StateFL

VIII. Authorized Official

Name: DR. MARK DEAN KORNHABER
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 954-499-4143