Healthcare Provider Details

I. General information

NPI: 1154440972
Provider Name (Legal Business Name): SEBASTOPOL ASC, L.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6880 PALM AVE
SEBASTOPOL CA
95472-4270
US

IV. Provider business mailing address

6880 PALM AVE
SEBASTOPOL CA
95472-4270
US

V. Phone/Fax

Practice location:
  • Phone: 707-823-7628
  • Fax: 707-823-1521
Mailing address:
  • Phone: 707-823-7628
  • Fax: 707-823-1521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number010000189
License Number StateCA

VIII. Authorized Official

Name: DR. ERIC J KAHLE
Title or Position: CORPORATE OFFICER
Credential: M.D.
Phone: 707-823-7628