Healthcare Provider Details

I. General information

NPI: 1194026930
Provider Name (Legal Business Name): CHRISTINE I DIMAIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2010
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5979 COMMERCE BLVD STE 10
ROHNERT PARK CA
94928-1650
US

IV. Provider business mailing address

5979 COMMERCE BLVD STE 10
ROHNERT PARK CA
94928-1650
US

V. Phone/Fax

Practice location:
  • Phone: 707-303-7261
  • Fax:
Mailing address:
  • Phone: 707-303-7261
  • Fax: 860-747-9500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCMF01542
License Number StateCT

VIII. Authorized Official

Name: CHRISTINE I DIMAIO
Title or Position: OWNER
Credential:
Phone: 707-303-7261