1689014615 NPI number — RELATIONSHIP CENTER FOR CHANGE A

Table of content: (NPI 1689014615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689014615 NPI number — RELATIONSHIP CENTER FOR CHANGE A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RELATIONSHIP CENTER FOR CHANGE A
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:
1689014615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 4TH ST
Provider Second Line Business Mailing Address:
#224
Provider Business Mailing Address City Name:
PETALUMA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94952-3040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-523-8009
Provider Business Mailing Address Fax Number:
707-766-0556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2455 BENNETT VALLEY RD STE C210
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:
95404-5671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-523-8009
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BUTLER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
707-523-8009

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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