=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922193556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAISER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 10/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19000 HOMESTEAD
-----------------------------------------------------
City | CUPERTINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-366-4151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 458
-----------------------------------------------------
City | POLLOCK PINES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-647-1813
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | MS. THERESA LYNN GILLILAND
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 408-366-4151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | NPF 11076
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------