Healthcare Provider Details

I. General information

NPI: 1760967079
Provider Name (Legal Business Name): PEMBROKE OPERATING COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W NASHVILLE ST
PEMBROKE KY
42266-9763
US

IV. Provider business mailing address

124 W NASHVILLE ST
PEMBROKE KY
42266-9763
US

V. Phone/Fax

Practice location:
  • Phone: 270-475-4227
  • Fax: 270-475-4173
Mailing address:
  • Phone: 270-475-4227
  • Fax: 270-475-4173

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: MOSHE KELMAN
Title or Position: MANAGING MEMBER
Credential:
Phone: 270-475-4227