=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508649914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KCS1, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2023
-----------------------------------------------------
Last Update Date | 08/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6901 OKEECHOBEE BLVD # D5-H28
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33411-2511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-283-1040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6901 OKEECHOBEE BLVD # D5-H28
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33411-2511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-283-1040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. SOFIA THOMAS
-----------------------------------------------------
Credential | DNP, APRN, FNP-C
-----------------------------------------------------
Telephone | 561-283-1040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------