Provider Demographics
NPI:1265596373
Name:PETALUMA ICF DDH INC
Entity type:Organization
Organization Name:PETALUMA ICF DDH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:HIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-894-3686
Mailing Address - Street 1:226 MERCED DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066
Mailing Address - Country:US
Mailing Address - Phone:650-872-3438
Mailing Address - Fax:650-872-6738
Practice Address - Street 1:805 PETALUMA AVE
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476
Practice Address - Country:US
Practice Address - Phone:707-938-9195
Practice Address - Fax:707-939-3519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55G416OtherMEDI CAL