Healthcare Provider Details

I. General information

NPI: 1598126161
Provider Name (Legal Business Name): PINE RIVER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 PENNSYLVANIA AVE STE D
FAIRFIELD CA
94533-3509
US

IV. Provider business mailing address

1620 PENNSYLVANIA AVE STE D
FAIRFIELD CA
94533-3509
US

V. Phone/Fax

Practice location:
  • Phone: 707-426-4327
  • Fax:
Mailing address:
  • Phone: 707-426-4327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State

VIII. Authorized Official

Name: DENISE MARTIN-SAHIM
Title or Position: OWNER
Credential:
Phone: 707-642-8862