MEDICARE: KOZIE KOTTAGE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	6906562	FL

General Provider Information

NPI Number	:	1609215938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOZIE KOTTAGE LLC

Provider Business Mailing Address
First Line	:	12576 54TH ST N
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-8512
Country	:	US
Telephone Number	:	561-236-9100
Fax Number	:

Provider Business Practice Location Address
First Line	:	12576 54TH ST N
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-8512
Country	:	US
Telephone Number	:	561-236-9100
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MISS WENDY ROSEMARIE REYES
Credential	:
Telephone Number	:	561-236-9100

Provider Enumeration Date	:	06/19/2013
Last Update Date	:	08/27/2013

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