Provider Demographics
NPI:1093854036
Name:SONOMA VALLEY COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:SONOMA VALLEY COMMUNITY HEALTH CENTER
Other - Org Name:SONOMA VALLEY COMMUNITY HEALTH CENTER MOBILE VAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARYL
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-939-6075
Mailing Address - Street 1:19270 SONOMA HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-5414
Mailing Address - Country:US
Mailing Address - Phone:707-939-6070
Mailing Address - Fax:707-939-6077
Practice Address - Street 1:19270 SONOMA HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-5414
Practice Address - Country:US
Practice Address - Phone:707-939-6070
Practice Address - Fax:707-939-6077
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SONOMA VALLEY COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-06
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000251261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC53855FMedicaid
CAHAP53855FMedicaid
CABCP53855FMedicaid
CABCP53855FMedicaid
CABCP53855FMedicaid