=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558154815
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN JOHN CROOMS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2025
-----------------------------------------------------
Last Update Date | 05/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13585 SAN PABLO AVE FL 1
-----------------------------------------------------
City | SAN PABLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94806-3863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-269-4271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 LINCOLN VILLAGE CIR APT 2235
-----------------------------------------------------
City | LARKSPUR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94939-1666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-269-4271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------