Provider Demographics
NPI:1679237796
Name:CHILCOTT MD INC
Entity Type:Organization
Organization Name:CHILCOTT MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-548-6825
Mailing Address - Street 1:1515 KJELL CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4519
Mailing Address - Country:US
Mailing Address - Phone:707-548-6825
Mailing Address - Fax:888-995-0195
Practice Address - Street 1:2800 CLEVELAND AVE STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2784
Practice Address - Country:US
Practice Address - Phone:707-548-6825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy