Healthcare Provider Details

I. General information

NPI: 1780938480
Provider Name (Legal Business Name): UKIAH VALLEY ANESTHESIA SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 KENNWOOD DR
UKIAH CA
95482-8769
US

IV. Provider business mailing address

509 KENNWOOD DR
UKIAH CA
95482-8769
US

V. Phone/Fax

Practice location:
  • Phone: 360-672-1401
  • Fax:
Mailing address:
  • Phone: 360-672-1401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC54671
License Number StateCA

VIII. Authorized Official

Name: E CHRISTOPHER OUTLUND
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 360-672-1401