Provider Demographics
NPI:1588663124
Name:COL NORTH CALIFORNIA, LLC
Entity Type:Organization
Organization Name:COL NORTH CALIFORNIA, LLC
Other - Org Name:PETALUMA OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:G
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-291-9161
Mailing Address - Street 1:181 LYNCH CREEK WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-2372
Mailing Address - Country:US
Mailing Address - Phone:707-766-7074
Mailing Address - Fax:707-766-7075
Practice Address - Street 1:181 LYNCH CREEK WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2372
Practice Address - Country:US
Practice Address - Phone:707-766-7074
Practice Address - Fax:707-766-7075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes293D00000XLaboratoriesPhysiological LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR004920DMedicaid
CAZZZ25448ZMedicare PIN
CAP00157411Medicare PIN