Healthcare Provider Details

I. General information

NPI: 1952555740
Provider Name (Legal Business Name): SANTA ROSA SPORTS MEDICINE, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2008
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 N DUTTON AVE
SANTA ROSA CA
95401-4663
US

IV. Provider business mailing address

1255 N DUTTON AVE
SANTA ROSA CA
95401-4663
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-9400
  • Fax: 707-546-9464
Mailing address:
  • Phone: 707-546-9400
  • Fax: 707-546-9464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberG073843
License Number StateCA

VIII. Authorized Official

Name: DR. TY PRESTON AFFLECK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 707-546-9400