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General NPI Number Information
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NPI Number | 1821202003
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Entity Type | Organization
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Legal Business Name | VASCULAR LABORATORY OF SANTA ROSA, INC.
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Dates
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Enumeration Date | 05/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1111 SONOMA AVE STE 322
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City | SANTA ROSA
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State | CA
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Zip | 95405-4820
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Country | US
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Telephone | 707-576-1522
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Fax | 707-576-1523
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Provider Business Mailing Address
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Address Line | 1111 SONOMA AVE STE 322
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City | SANTA ROSA
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State | CA
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Zip | 95405-4820
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Country | US
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Telephone | 707-576-1522
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Fax | 707-576-1523
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | MR. ROBERT RICHARDSON
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Credential | M.D.
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Telephone | 707-545-2436
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2471V0105X
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Taxonomy Name | Vascular Sonography Radiologic Technologist
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License Number | C1090923
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License Number State | CA
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