Provider Demographics
NPI:1376629998
Name:PENINSULA BIOMEDICAL, INC.
Entity Type:Organization
Organization Name:PENINSULA BIOMEDICAL, INC.
Other - Org Name:PENINSULA MEDICAL, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRISWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-430-9066
Mailing Address - Street 1:15 CAMP EVERS LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-4128
Mailing Address - Country:US
Mailing Address - Phone:831-430-9066
Mailing Address - Fax:831-430-9068
Practice Address - Street 1:15 CAMP EVERS LN
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4128
Practice Address - Country:US
Practice Address - Phone:831-430-9066
Practice Address - Fax:831-430-9068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1196930001332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4549517Medicaid
WI82712600Medicaid
WA9048612Medicaid
CO29401372Medicaid
OH2107491Medicaid
VA9102475Medicaid
VA9102475Medicaid
OH2107491Medicaid