Healthcare Provider Details

I. General information

NPI: 1962890103
Provider Name (Legal Business Name): SPECTRUMCARE REHABILITATION MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 VILLA LN STE 150
NAPA CA
94558-6449
US

IV. Provider business mailing address

3434 VILLA LN STE 150
NAPA CA
94558-6449
US

V. Phone/Fax

Practice location:
  • Phone: 707-252-4507
  • Fax: 707-258-2780
Mailing address:
  • Phone: 707-252-4507
  • Fax: 707-258-2780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG64848
License Number StateCA

VIII. Authorized Official

Name: MRS. DARLA HARRISON
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential: CMM
Phone: 707-252-4507