Basic Information
| Provider Information | |||||||||
| NPI: | 1154590958 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMA MEDICAL FOUNDATION SEBASTOPOL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRIMA MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 HAMILTON LNDG STE 100 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949498247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158841840 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 652 PETALUMA AVE | ||||||||
| Address2: | SUITE H | ||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954724256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078237616 | ||||||||
| FaxNumber: | 7078232803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | MONDRAGON | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4158841840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIMA MEDICAL FOUNDATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.