Basic Information
| Provider Information | |||||||||
| NPI: | 1598807190 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY ACTION PARTNERSHIP OF SONOMA COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ROSELAND CHILDREN'S HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 N DUTTON AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954014610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075446911 | ||||||||
| FaxNumber: | 7075262918 | ||||||||
| Practice Location | |||||||||
| Address1: | 962 SEBASTOPOL RD | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954076829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075782005 | ||||||||
| FaxNumber: | 7075788037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEMKE | ||||||||
| AuthorizedOfficialFirstName: | HELGA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7075446911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | CMM70706F | 05 | CA | MEDICAID |