Provider Demographics
NPI:1588795058
Name:GOSS, KEVIN BARRIE
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:BARRIE
Last Name:GOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95947-0039
Mailing Address - Country:US
Mailing Address - Phone:530-284-6618
Mailing Address - Fax:
Practice Address - Street 1:225 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:CA
Practice Address - Zip Code:95947-0039
Practice Address - Country:US
Practice Address - Phone:530-284-6618
Practice Address - Fax:530-284-6940
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9891183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC6374930OtherDRIVERS LICENSE