Healthcare Provider Details

I. General information

NPI: 1154590958
Provider Name (Legal Business Name): PRIMA MEDICAL FOUNDATION SEBASTOPOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 PETALUMA AVE SUITE H
SEBASTOPOL CA
95472-4256
US

IV. Provider business mailing address

4 HAMILTON LNDG STE 100
NOVATO CA
94949-8247
US

V. Phone/Fax

Practice location:
  • Phone: 707-823-7616
  • Fax: 707-823-2803
Mailing address:
  • Phone: 415-884-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DENNIS MONDRAGON
Title or Position: COO
Credential:
Phone: 415-884-1840