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General NPI Number Information
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NPI Number | 1871690057
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Entity Type | Organization
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Legal Business Name | SISKIYOU RURAL HOUSECALLS MEDICAL CORPORATION
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1296 SCHEIBEL LN
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City | SEBASTOPOL
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State | CA
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Zip | 95472-4717
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Country | US
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Telephone | 707-884-9004
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Fax | 707-823-3856
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Provider Business Mailing Address
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Address Line | 1296 SCHEIBEL LN
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City | SEBASTOPOL
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State | CA
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Zip | 95472-4717
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Country | US
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Telephone | 707-884-9004
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Fax | 707-823-3856
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. JUDITH T. WALENTA
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Credential | FNP
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Telephone | 707-884-9004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 20A5992
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License Number State | CA
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