Provider Demographics
NPI:1528576675
Name:PETALUMA SPECIALTY CENTER, LLC.
Entity Type:Organization
Organization Name:PETALUMA SPECIALTY CENTER, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ISHU
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-981-7995
Mailing Address - Street 1:392 TESCONI CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4653
Mailing Address - Country:US
Mailing Address - Phone:707-981-7995
Mailing Address - Fax:707-981-7912
Practice Address - Street 1:1456 PROFESSIONAL DR STE 404
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6639
Practice Address - Country:US
Practice Address - Phone:707-981-7995
Practice Address - Fax:707-981-7912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical