Provider Demographics
NPI:1114071453
Name:DEPARTMENT OF HEALTH SERVICES
Entity Type:Organization
Organization Name:DEPARTMENT OF HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT III COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:STORNETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-565-4782
Mailing Address - Street 1:PO BOX 1539
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95402-1539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 N. PYTHIAN ROAD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409
Practice Address - Country:US
Practice Address - Phone:707-565-6350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SONOMA DEPT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-23
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR11473FOtherCALIFORNIA MEDI-CAL