Provider Demographics
NPI:1285631978
Name:SANTA ROSA TREATMENT PROGRAM, INC.
Entity Type:Organization
Organization Name:SANTA ROSA TREATMENT PROGRAM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-576-0818
Mailing Address - Street 1:625 STEELE LANE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3127
Mailing Address - Country:US
Mailing Address - Phone:707-576-0818
Mailing Address - Fax:707-576-7845
Practice Address - Street 1:625 STEELE LANE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3127
Practice Address - Country:US
Practice Address - Phone:707-576-0818
Practice Address - Fax:707-576-7845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49-02261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3631909OtherEDD STATE PROVIDER
CA-10228-MOtherCSAT (SAMHSA)
CA49-02OtherDHCS NTP
CA49ACMedicaid
CA49-02OtherDHCS NTP
CA49ACMedicaid