Provider Demographics
NPI:1578631172
Name:SANTA ROSA COMMUNITY HEALTH CENTERS
Entity Type:Organization
Organization Name:SANTA ROSA COMMUNITY HEALTH CENTERS
Other - Org Name:VISTA CAMPUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNAL-LEROI
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:707-303-3600
Mailing Address - Street 1:3569 ROUND BARN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-5781
Mailing Address - Country:US
Mailing Address - Phone:707-303-3600
Mailing Address - Fax:707-303-3635
Practice Address - Street 1:3569 ROUND BARN CIRCLE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-5781
Practice Address - Country:US
Practice Address - Phone:707-303-3600
Practice Address - Fax:707-303-3635
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANTA ROSA COMMUNITY HEALTH CENTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-01
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000087261Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC71099FMedicaid
CAFHC71099FMedicaid