1487857991 NPI number — SANTA ROSA COMMUNITY HEALTH CENTERS

Table of content: (NPI 1487857991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487857991 NPI number — SANTA ROSA COMMUNITY HEALTH CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTA ROSA COMMUNITY HEALTH CENTERS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHWEST COMMUNITY HEALTH CENTER
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487857991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3569 ROUND BARN CIRCLE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95403-5781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-303-3600
Provider Business Mailing Address Fax Number:
707-303-3635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
751 LOMBARDI COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95407-6793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-547-2222
Provider Business Practice Location Address Fax Number:
707-527-0472
Provider Enumeration Date:
06/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BERNAL-LEROI
Authorized Official First Name:
GABRIELA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
707-303-3600

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  110000300 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: BCP70663F . This is a "CDP ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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