Organization Name: | PRIMA MEDICAL FOUNDATION SEBASTOPOL |
NPI Number: | 1154590958 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | DENNIS MONDRAGON (COO) |
Mailing Address: | 652 Petaluma Ave Suite H Sebastopol |
State: | CA US |
Postal Code: | 954724256 |
Phone Number: | 7078237616 |
Fax Number: | 7078232803 |
NPI Enumeration Date: | 02/26/2008 |
NPI Last Update Date: | 04/24/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QP2300X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Primary Care |
Taxonomy Definition: |