Healthcare Provider Details

I. General information

NPI: 1720467962
Provider Name (Legal Business Name): BOUCH MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 PETALUMA AVE STE 150
SEBASTOPOL CA
95472-4273
US

IV. Provider business mailing address

435 PETALUMA AVE STE 150
SEBASTOPOL CA
95472-4273
US

V. Phone/Fax

Practice location:
  • Phone: 707-861-7300
  • Fax: 707-823-8568
Mailing address:
  • Phone: 707-861-7300
  • Fax: 707-823-8568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number20A9470
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG55518
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberND-353
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberND-613
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number393692
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG35969
License Number StateCA

VIII. Authorized Official

Name: SUMMER BEGIN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 707-861-7300