Basic Information
| Provider Information | |||||||||
| NPI: | 1780195255 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANTA ROSA COMMUNITY HEALTH CENTERS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DUTTON CAMPUS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3569 ROUND BARN CIR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954035781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073033600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 N DUTTON AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954017112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073033600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | BROCKMAN | ||||||||
| AuthorizedOfficialFirstName: | HAROLD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7073033600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SANTA ROSA COMMUNITY HEALTH CENTERS | ||||||||
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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.