Provider Demographics
NPI:1558891325
Name:NORTHBAY HEALTHCARE GROUP
Entity Type:Organization
Organization Name:NORTHBAY HEALTHCARE GROUP
Other - Org Name:NORTHBAY SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR, REVENUE CYCLE MGMT
Authorized Official - Prefix:
Authorized Official - First Name:LORIANN
Authorized Official - Middle Name:
Authorized Official - Last Name:EICHENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-646-3400
Mailing Address - Street 1:1020 NUT TREE RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4100
Mailing Address - Country:US
Mailing Address - Phone:707-624-8066
Mailing Address - Fax:707-624-7360
Practice Address - Street 1:1020 NUT TREE RD
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-4100
Practice Address - Country:US
Practice Address - Phone:707-624-8066
Practice Address - Fax:707-624-7360
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHBAY HEALTHCARE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA544003336C0003X
3336C0004X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5663477Medicaid