Provider Demographics
NPI:1689742215
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:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:FUCHS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-303-3091
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 1:684 BENECIA DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-3058
Practice Address - Country:US
Practice Address - Phone:707-573-4565
Practice Address - Fax:707-576-6687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000491261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAADUF0034GMedicaid