Healthcare Provider Details

I. General information

NPI: 1104413517
Provider Name (Legal Business Name): NORTH BAY POST ACUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2020
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 DOUGLAS ST
PETALUMA CA
94952-2503
US

IV. Provider business mailing address

5404 WHITSETT AVE STE 182
VALLEY VILLAGE CA
91607-1615
US

V. Phone/Fax

Practice location:
  • Phone: 707-763-6887
  • Fax:
Mailing address:
  • Phone: 818-960-0295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: BRYAN TANNER
Title or Position: MANAGER
Credential:
Phone: 707-763-6887