Basic Information
| Provider Information | |||||||||
| NPI: | 1760584049 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PETALUMA HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BOLINAS FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1455 N MCDOWELL BLVD STE D | ||||||||
| Address2: | |||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949546503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075597500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 88 MESA RD | ||||||||
| Address2: | |||||||||
| City: | BOLINAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949249713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158680124 | ||||||||
| FaxNumber: | 4158682152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOUANEH | ||||||||
| AuthorizedOfficialFirstName: | MOLLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7075597500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 110000397 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC03885G | 05 | CA | MEDICAID |