Provider Demographics
NPI:1245739697
Name:SANTA ROSA COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:SANTA ROSA COMMUNITY HEALTH CENTER
Other - Org Name:AIRWAY CAMPUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-583-8839
Mailing Address - Street 1:3569 ROUND BARN CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-5781
Mailing Address - Country:US
Mailing Address - Phone:707-303-3600
Mailing Address - Fax:707-396-5155
Practice Address - Street 1:3883 AIRWAY DR STE 202
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1671
Practice Address - Country:US
Practice Address - Phone:707-583-8748
Practice Address - Fax:707-236-6919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)