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General NPI Number Information
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NPI Number | 1326259276
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Entity Type | Organization
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Legal Business Name | PETALUMA SURGICENTER
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Dates
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Enumeration Date | 05/24/2007
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Last Update Date | 01/10/2013
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Provider Practice Location Address
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Address Line | 1400 PROFESSIONAL DR SUITE 102
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City | PETALUMA
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State | CA
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Zip | 94954-5110
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Country | US
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Telephone | 707-763-9325
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Fax | 707-769-0751
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Provider Business Mailing Address
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Address Line | 1400 PROFESSIONAL DR SUITE 102
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City | PETALUMA
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State | CA
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Zip | 94954-5110
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Country | US
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Telephone | 707-763-9325
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Fax | 707-769-0751
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Authorized Official
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Title or Position | OWNER
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Name | RONALD LAVIGNA
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Credential | DPM
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Telephone | 707-763-9325
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP1100X
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Taxonomy Name | Podiatric Clinic/Center
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License Number | 110000263
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License Number State | CA
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