Basic Information
Provider Information | |||||||||
NPI: | 1194824573 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH SONOMA COUNTY HEALTH CARE DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEALDSBURG DISTRICT HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1375 UNIVERSITY AVE. | ||||||||
Address2: |   | ||||||||
City: | HEALDSBURG | ||||||||
State: | CA | ||||||||
PostalCode: | 954483382 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074316500 | ||||||||
FaxNumber: | 7074316588 | ||||||||
Practice Location | |||||||||
Address1: | 1375 UNIVERSITY AVE. | ||||||||
Address2: |   | ||||||||
City: | HEALDSBURG | ||||||||
State: | CA | ||||||||
PostalCode: | 954483382 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074316500 | ||||||||
FaxNumber: | 7074316588 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2006 | ||||||||
LastUpdateDate: | 03/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BALAND | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7072399068 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: | 03/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 110000019 | CA | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | HSP40331I | 05 | CA |   | MEDICAID | ZZR00331I | 05 | CA |   | MEDICAID |