Provider Demographics
NPI:1760559447
Name:SONOMA DIABETIC SUPPLIES
Entity Type:Organization
Organization Name:SONOMA DIABETIC SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:FANUCCCHI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:707-938-2667
Mailing Address - Street 1:246 PERKINS ST
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-6954
Mailing Address - Country:US
Mailing Address - Phone:707-938-2667
Mailing Address - Fax:707-938-5402
Practice Address - Street 1:246 PERKINS ST
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-6954
Practice Address - Country:US
Practice Address - Phone:707-938-2667
Practice Address - Fax:707-938-5402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHA462690332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA462690Medicaid
CA0329770001Medicare NSC