Healthcare Provider Details

I. General information

NPI: 1093229312
Provider Name (Legal Business Name): NORTHERN CALIFORNIA MEDICAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2017
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 S MAIN ST
SEBASTOPOL CA
95472-4261
US

IV. Provider business mailing address

3536 MENDOCINO AVE STE 200
SANTA ROSA CA
95403-3634
US

V. Phone/Fax

Practice location:
  • Phone: 707-829-5455
  • Fax: 707-824-9235
Mailing address:
  • Phone: 707-525-6485
  • Fax: 707-573-6918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5942
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number20A5942
License Number StateCA

VIII. Authorized Official

Name: SALLY A DEWALD
Title or Position: DIRECTOR OF BUSINESS SERVICES
Credential:
Phone: 707-525-6485