Healthcare Provider Details

I. General information

NPI: 1760665178
Provider Name (Legal Business Name): PALM DRIVE NURSING & REHAB CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 PETALUMA AVE
SEBASTOPOL CA
95472-4206
US

IV. Provider business mailing address

501 PETALUMA AVE
SEBASTOPOL CA
95472-4215
US

V. Phone/Fax

Practice location:
  • Phone: 707-823-8511
  • Fax: 707-829-4136
Mailing address:
  • Phone: 707-823-8511
  • Fax: 707-829-4136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: MRS. LORI AUSTIN
Title or Position: COO
Credential:
Phone: 707-829-4300