Healthcare Provider Details

I. General information

NPI: 1114071453
Provider Name (Legal Business Name): DEPARTMENT OF HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N. PYTHIAN ROAD
SANTA ROSA CA
95409
US

IV. Provider business mailing address

PO BOX 1539
SANTA ROSA CA
95402-1539
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-6350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIANA STORNETTA
Title or Position: ACCOUNTANT III COMPLIANCE
Credential:
Phone: 707-565-4782