Healthcare Provider Details

I. General information

NPI: 1922764414
Provider Name (Legal Business Name): RAJNAL JAGDISH LAL EMT-B
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

IV. Provider business mailing address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

V. Phone/Fax

Practice location:
  • Phone: 707-393-4000
  • Fax:
Mailing address:
  • Phone: 707-393-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberE033132
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: