Healthcare Provider Details

I. General information

NPI: 1487895975
Provider Name (Legal Business Name): DREW HITTENBERGER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 LYNCH CREEK SUITE 101
PETALUMA CA
94954
US

IV. Provider business mailing address

1111 SONOMA AVE SUITE 320
SANTA ROSA CA
95405-4819
US

V. Phone/Fax

Practice location:
  • Phone: 707-765-1122
  • Fax: 707-765-4571
Mailing address:
  • Phone: 707-765-1122
  • Fax: 707-765-4571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCP 1093
License Number StateDE

VIII. Authorized Official

Name: DREW ARNOLD HITTENBERGER
Title or Position: OWNER
Credential: CP BOC
Phone: 707-765-1122