Healthcare Provider Details

I. General information

NPI: 1376510586
Provider Name (Legal Business Name): ST. HELENA OB/GYN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15322 LAKESHORE DR SUITE 102
CLEARLAKE CA
95422-9814
US

IV. Provider business mailing address

15322 LAKESHORE DR SUITE 102
CLEARLAKE CA
95422-9814
US

V. Phone/Fax

Practice location:
  • Phone: 707-995-0193
  • Fax:
Mailing address:
  • Phone: 707-995-0193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: RENEE W SOLOMON
Title or Position: MEDICAL GROUP COORDINATOR
Credential:
Phone: 707-968-2870