Healthcare Provider Details

I. General information

NPI: 1619390077
Provider Name (Legal Business Name): NORTHERN CALIFORNIA MEDICAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 PARK ST
LAKEPORT CA
95453-4803
US

IV. Provider business mailing address

3536 MENDOCINO AVE STE 200
SANTA ROSA CA
95403-3634
US

V. Phone/Fax

Practice location:
  • Phone: 707-263-9595
  • Fax: 707-263-5576
Mailing address:
  • Phone: 707-525-6485
  • Fax: 707-573-6918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MS. RUTH A SKIDMORE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 707-573-6925