Basic Information
| Provider Information | |||||||||
| NPI: | 1215520614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILFOY | ||||||||
| FirstName: | STELLA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2546 STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921011316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737061569 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7090 MIRATECH DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921213109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583046440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2021 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 106S00000X | RBT-21-155208 | CA | Y |
No ID Information.