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General NPI Number Information
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NPI Number | 1528576675
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Entity Type | Organization
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Legal Business Name | PETALUMA SPECIALTY CENTER, LLC.
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Dates
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Enumeration Date | 01/10/2018
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Last Update Date | 04/12/2018
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Provider Practice Location Address
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Address Line | 1456 PROFESSIONAL DR STE 404
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City | PETALUMA
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State | CA
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Zip | 94954-6639
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Country | US
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Telephone | 707-981-7995
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Fax | 707-981-7912
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Provider Business Mailing Address
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Address Line | 392 TESCONI CT
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City | SANTA ROSA
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State | CA
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Zip | 95401-4653
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Country | US
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Telephone | 707-981-7995
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Fax | 707-981-7912
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL ISHU YANG
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Credential | MD
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Telephone | 707-981-7995
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State | CA
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