=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558891325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHBAY HEALTHCARE GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 NUT TREE RD
-----------------------------------------------------
City | VACAVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95687-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-624-8066
-----------------------------------------------------
Fax | 707-624-7360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1020 NUT TREE RD
-----------------------------------------------------
City | VACAVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95687-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-624-8066
-----------------------------------------------------
Fax | 707-624-7360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR DIRECTOR, REVENUE CYCLE MGMT
-----------------------------------------------------
Name | LORIANN EICHENBERGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-646-3400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 54400
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------