Healthcare Provider Details

I. General information

NPI: 1477375772
Provider Name (Legal Business Name): EDWARD RILEY FOX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 NEOTOMAS AVE
SANTA ROSA CA
95405-7575
US

IV. Provider business mailing address

1430 NEOTOMAS AVE
SANTA ROSA CA
95405-7575
US

V. Phone/Fax

Practice location:
  • Phone: 707-571-5581
  • Fax: 707-571-5531
Mailing address:
  • Phone: 707-571-5581
  • Fax: 707-571-5531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: