Basic Information
| Provider Information | |||||||||
| NPI: | 1043308539 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH SONOMA COUNTY HEALTH CARE DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HEALDSBURG DISTRICT HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1375 UNIVERSITY ST | ||||||||
| Address2: | |||||||||
| City: | HEALDSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954483382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074316500 | ||||||||
| FaxNumber: | 7074316588 | ||||||||
| Practice Location | |||||||||
| Address1: | 1375 UNIVERSITY ST | ||||||||
| Address2: | |||||||||
| City: | HEALDSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954483382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074316500 | ||||||||
| FaxNumber: | 7074316588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALAND | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7072399068 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 110000019 | CA | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | LTC30331I | 05 | CA | MEDICAID |