Provider Demographics
NPI:1720070071
Name:NORTHBAY HEALTHCARE GROUP
Entity Type:Organization
Organization Name:NORTHBAY HEALTHCARE GROUP
Other - Org Name:NORTHBAY HOSPICE AND BEREAVEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:AMBULATORY DIVISION PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-646-5700
Mailing Address - Street 1:4500 BUSINESS CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-6888
Mailing Address - Country:US
Mailing Address - Phone:707-646-3575
Mailing Address - Fax:707-646-3576
Practice Address - Street 1:4520 BUSINESS CENTER DRIVE
Practice Address - Street 2:SUITE 160
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-6888
Practice Address - Country:US
Practice Address - Phone:707-646-3575
Practice Address - Fax:707-646-3576
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHBAY HEALTHCARE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-22
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000037251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHPC01651FMedicaid
CAHPC01651FMedicaid