1235782921 NPI number — NORTHERN CALIFORNIA MEDICAL ASSOC INC

Table of content: (NPI 1235782921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235782921 NPI number — NORTHERN CALIFORNIA MEDICAL ASSOC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN CALIFORNIA MEDICAL ASSOC INC
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:
1235782921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3536 MENDOCINO AVE STE 200
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:
95403-3634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-545-6485
Provider Business Mailing Address Fax Number:
707-573-6918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4727 HOEN AVE STE A
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:
95405-7898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-527-0342
Provider Business Practice Location Address Fax Number:
707-527-0818
Provider Enumeration Date:
07/22/2019

Additional Information

Authorized Official

Authorized Official Last Name:
DEWALD
Authorized Official First Name:
SALLY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BUSINESS SERVICES MANAGER
Authorized Official Telephone Number:
707-525-6485

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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