Healthcare Provider Details

I. General information

NPI: 1629902689
Provider Name (Legal Business Name): JAMES KILGORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 S PROSPECT AVE STE A
TUSTIN CA
92780-1523
US

IV. Provider business mailing address

412 N EMILY ST
ANAHEIM CA
92805-3028
US

V. Phone/Fax

Practice location:
  • Phone: 949-312-1232
  • Fax:
Mailing address:
  • Phone: 909-680-7372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: