Healthcare Provider Details

I. General information

NPI: 1073181491
Provider Name (Legal Business Name): CARLOS HUMBERTO MURCIA I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2021
Last Update Date: 06/13/2021
Certification Date: 06/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 SLATER ST
SANTA ROSA CA
95404-2816
US

IV. Provider business mailing address

1701 SLATER ST
SANTA ROSA CA
95404-2816
US

V. Phone/Fax

Practice location:
  • Phone: 707-321-4809
  • Fax:
Mailing address:
  • Phone: 707-321-4809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number86291705
License Number State
# 2
Primary TaxonomyY
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number339359
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: