1245739697 NPI number — SANTA ROSA COMMUNITY HEALTH CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245739697 NPI number — SANTA ROSA COMMUNITY HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTA ROSA COMMUNITY HEALTH CENTER
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:
Provider Other Organization Name Type Code:
6
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:
1245739697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3569 ROUND BARN CIR
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:
707-396-5155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3883 AIRWAY DR STE 202
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:
95403-1671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-583-8748
Provider Business Practice Location Address Fax Number:
707-236-6919
Provider Enumeration Date:
02/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BROCKMAN
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
707-583-8839

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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