Provider Demographics
NPI:1568665073
Name:SANTA ROSA COMMUNITY HEALTH CENTERS
Entity Type:Organization
Organization Name:SANTA ROSA COMMUNITY HEALTH CENTERS
Other - Org Name:SOUTHWEST COMMUNITY HEALTH CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
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 1:599 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-7713
Mailing Address - Country:US
Mailing Address - Phone:707-547-2220
Mailing Address - Fax:707-303-3182
Practice Address - Street 1:599 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7713
Practice Address - Country:US
Practice Address - Phone:707-547-2220
Practice Address - Fax:707-303-3182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000489261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP70937FOtherFAMILY PACT ID