MEDICARE: R HOUSE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	4931	CA

General Provider Information

NPI Number	:	1205030103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R HOUSE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 2587
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-0587
Country	:	US
Telephone Number	:	707-571-2215
Fax Number	:	707-526-9672

Provider Business Practice Location Address
First Line	:	1207 CLEVELAND AVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95401-4729
Country	:	US
Telephone Number	:	707-568-4492
Fax Number	:	707-526-9672

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MIMI G. DONOHUE
Credential	:
Telephone Number	:	707-571-2215

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	05/27/2011

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