Provider Demographics
NPI:1881871341
Name:SANTA ROSA FAMILY CARE CENTER
Entity type:Organization
Organization Name:SANTA ROSA FAMILY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:323-583-6814
Mailing Address - Street 1:1234 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-2433
Mailing Address - Country:US
Mailing Address - Phone:323-583-6814
Mailing Address - Fax:323-583-6818
Practice Address - Street 1:1234 E FLORENCE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-2433
Practice Address - Country:US
Practice Address - Phone:323-583-6814
Practice Address - Fax:323-583-6818
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANTA ROSA FAMILY CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-28
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGNP000151Medicaid