Healthcare Provider Details

I. General information

NPI: 1023404381
Provider Name (Legal Business Name): STEPHEN KUO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14700 MANZANITA PARK ROAD
BEAUMONT CA
92223
US

IV. Provider business mailing address

1561 WILLOW PL
BANNING CA
92220-1133
US

V. Phone/Fax

Practice location:
  • Phone: 951-845-3155
  • Fax: 951-845-8412
Mailing address:
  • Phone: 951-845-3155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: