Healthcare Provider Details

I. General information

NPI: 1902038573
Provider Name (Legal Business Name): UKIAH VALLEY PRIMARY CARE MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 08/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 HOSPITAL DR STE A
UKIAH CA
95482-4558
US

IV. Provider business mailing address

PO BOX 2739
UKIAH CA
95482-2739
US

V. Phone/Fax

Practice location:
  • Phone: 707-463-8000
  • Fax: 707-463-8006
Mailing address:
  • Phone: 707-463-8000
  • Fax: 707-463-8006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA43219
License Number StateCA

VIII. Authorized Official

Name: DARCIE ANNE ANTLE
Title or Position: ADMINISTRATOR
Credential:
Phone: 707-463-8000