Basic Information
| Provider Information | |||||||||
| NPI: | 1558512624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANTA ROSA COMMUNITY HEALTH CENTERS | ||||||||
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| OtherOrganizationName: | SOUTHWEST COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3569 ROUND BARN CIRCLE | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954035781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073033600 | ||||||||
| FaxNumber: | 7073033635 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 STONY POINT RD STE 17 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954076848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075782005 | ||||||||
| FaxNumber: | 7075788037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2008 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | BROCKMAN | ||||||||
| AuthorizedOfficialFirstName: | HAROLD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7075838839 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.