Healthcare Provider Details

I. General information

NPI: 1669661716
Provider Name (Legal Business Name): PETALUMA SKILLED NURSING & WELLNESS CENTRE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 HAYES LN
PETALUMA CA
94952-4011
US

IV. Provider business mailing address

5120 W GOLDLEAF CIR SUITE 400
LOS ANGELES CA
90056-1292
US

V. Phone/Fax

Practice location:
  • Phone: 707-763-2457
  • Fax: 707-765-2176
Mailing address:
  • Phone: 310-574-3733
  • Fax: 310-574-1322

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: MR. STEPHEN E. REISSMAN
Title or Position: CEO
Credential:
Phone: 310-574-3733