=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952555740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANTA ROSA SPORTS MEDICINE, INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2008
-----------------------------------------------------
Last Update Date | 10/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1255 N DUTTON AVE
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95401-4663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-546-9400
-----------------------------------------------------
Fax | 707-546-9464
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1255 N DUTTON AVE
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95401-4663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-546-9400
-----------------------------------------------------
Fax | 707-546-9464
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TY PRESTON AFFLECK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 707-546-9400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | G073843
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------