Healthcare Provider Details

I. General information

NPI: 1417294174
Provider Name (Legal Business Name): ENTEGRATIVE OTOLARYNGOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 01/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 SONOMA AVE STE 101
SANTA ROSA CA
95405-4812
US

IV. Provider business mailing address

1144 SONOMA AVE STE 101
SANTA ROSA CA
95405-4812
US

V. Phone/Fax

Practice location:
  • Phone: 707-775-0775
  • Fax:
Mailing address:
  • Phone: 707-775-0775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberC3527438
License Number StateCA

VIII. Authorized Official

Name: LARRY KYLE GAMBRELL
Title or Position: DIRECTOR/CEO
Credential: D.O.
Phone: 267-456-4848