1528576675 NPI number — PETALUMA SPECIALTY CENTER, LLC.

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 1528576675 NPI number — PETALUMA SPECIALTY CENTER, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETALUMA SPECIALTY CENTER, LLC.
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:
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:
1528576675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
392 TESCONI CT
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:
95401-4653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-981-7995
Provider Business Mailing Address Fax Number:
707-981-7912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1456 PROFESSIONAL DR STE 404
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETALUMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94954-6639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-981-7995
Provider Business Practice Location Address Fax Number:
707-981-7912
Provider Enumeration Date:
01/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
YANG
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
ISHU
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
707-981-7995

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , 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)





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