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General NPI Number Information
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NPI Number | 1760732002
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Entity Type | Organization
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Legal Business Name | SONOMA RECOVERY SERVICES, LLC
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Dates
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Enumeration Date | 09/13/2012
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Last Update Date | 09/13/2012
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Provider Practice Location Address
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Address Line | 11207 VALLEY FORD RD
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City | PETALUMA
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State | CA
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Zip | 94952-3700
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Country | US
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Telephone | 707-795-7609
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Fax |
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Provider Business Mailing Address
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Address Line | 11207 VALLEY FORD RD
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City | PETALUMA
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State | CA
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Zip | 94952-3700
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Country | US
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Telephone | 707-795-7609
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER/EXECUTIVE DIRECTOR
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Name | DR. WAYNE C THURSTON
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Credential | PSY.D.
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Telephone | 707-795-7609
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State | CA
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