Provider Demographics
NPI:1760584049
Name:PETALUMA HEALTH CENTER INC
Entity Type:Organization
Organization Name:PETALUMA HEALTH CENTER INC
Other - Org Name:BOLINAS FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOUANEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-559-7500
Mailing Address - Street 1:1455 N MCDOWELL BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6503
Mailing Address - Country:US
Mailing Address - Phone:707-559-7500
Mailing Address - Fax:
Practice Address - Street 1:88 MESA RD
Practice Address - Street 2:
Practice Address - City:BOLINAS
Practice Address - State:CA
Practice Address - Zip Code:94924-9713
Practice Address - Country:US
Practice Address - Phone:415-868-0124
Practice Address - Fax:415-868-2152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000397261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03885GMedicaid
CA551912Medicare Oscar/Certification