Healthcare Provider Details

I. General information

NPI: 1194515106
Provider Name (Legal Business Name): RELYMD VIRTUAL HEALTH CA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5341 OLD REDWOOD HWY STE 210
PETALUMA CA
94954-7127
US

IV. Provider business mailing address

5341 OLD REDWOOD HWY STE 210
PETALUMA CA
94954-7127
US

V. Phone/Fax

Practice location:
  • Phone: 770-874-5400
  • Fax:
Mailing address:
  • Phone: 770-874-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM LARSEN
Title or Position: VP, CREDENTIALING
Credential:
Phone: 770-874-5400