Provider Demographics
NPI:1700188240
Name:COSGROVE, BRIAN WILLIAM JR (BA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:COSGROVE
Suffix:JR
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16225 SIERRA WAY
Mailing Address - Street 2:
Mailing Address - City:KERNVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93238-9709
Mailing Address - Country:US
Mailing Address - Phone:760-793-3824
Mailing Address - Fax:
Practice Address - Street 1:2731 NUGGET AVE
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240
Practice Address - Country:US
Practice Address - Phone:760-379-3412
Practice Address - Fax:760-379-5332
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator