Healthcare Provider Details

I. General information

NPI: 1619405222
Provider Name (Legal Business Name): PGB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 05/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 WESTGATE DR
BETHLEHEM PA
18017-7480
US

IV. Provider business mailing address

4329 REXFORD DR
BETHLEHEM PA
18020-9314
US

V. Phone/Fax

Practice location:
  • Phone: 917-306-5578
  • Fax: 610-419-4611
Mailing address:
  • Phone: 917-306-5578
  • Fax: 610-419-4611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HIREN B PATEL
Title or Position: MEMBER
Credential:
Phone: 917-306-5578