Basic Information
| Provider Information | |||||||||
| NPI: | 1649467986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILGORE | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 E 31ST STREET | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104376471 | ||||||||
| FaxNumber: | 5104374613 | ||||||||
| Practice Location | |||||||||
| Address1: | 15400 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108954343 | ||||||||
| FaxNumber: | 5108954333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 10/01/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0400X | RN405141 | CA | Y | Nursing Service Providers | Registered Nurse | Case Management |
No ID Information.