Provider Demographics
NPI:1588656268
Name:PETALUMA HEALTH CENTER INC
Entity Type:Organization
Organization Name:PETALUMA HEALTH CENTER INC
Other - Org Name:PETALUMA HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-559-7500
Mailing Address - Street 1:1179 N MCDOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6559
Mailing Address - Country:US
Mailing Address - Phone:707-559-7597
Mailing Address - Fax:707-658-1319
Practice Address - Street 1:1179 N MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6559
Practice Address - Country:US
Practice Address - Phone:707-559-7500
Practice Address - Fax:707-559-7620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCP70696FMedicaid
CAEAP70696FMedicaid
CAFHC70696FMedicaid
CA551879OtherMEDICARE NGS
CAHAP70696FMedicaid
CABCP70696FMedicaid
CA551879Medicare Oscar/Certification