Provider Demographics
NPI:1821202003
Name:VASCULAR LABORATORY OF SANTA ROSA, INC.
Entity Type:Organization
Organization Name:VASCULAR LABORATORY OF SANTA ROSA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-545-2436
Mailing Address - Street 1:1111 SONOMA AVE STE 322
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4820
Mailing Address - Country:US
Mailing Address - Phone:707-576-1522
Mailing Address - Fax:707-576-1523
Practice Address - Street 1:1111 SONOMA AVE STE 322
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4820
Practice Address - Country:US
Practice Address - Phone:707-576-1522
Practice Address - Fax:707-576-1523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC10909232471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0006300Medicaid
CAZZZ15745ZMedicare ID - Type UnspecifiedPROVIDER NUMBER