Basic Information
Provider Information | |||||||||
NPI: | 1285631978 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SANTA ROSA TREATMENT PROGRAM, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 625 STEELE LANE | ||||||||
Address2: |   | ||||||||
City: | SANTA ROSA | ||||||||
State: | CA | ||||||||
PostalCode: | 954033127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075760818 | ||||||||
FaxNumber: | 7075767845 | ||||||||
Practice Location | |||||||||
Address1: | 625 STEELE LANE | ||||||||
Address2: |   | ||||||||
City: | SANTA ROSA | ||||||||
State: | CA | ||||||||
PostalCode: | 954033127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075760818 | ||||||||
FaxNumber: | 7075767845 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 07/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TILLMAN | ||||||||
AuthorizedOfficialFirstName: | LEE | ||||||||
AuthorizedOfficialMiddleName: | ROY | ||||||||
AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR/CEO | ||||||||
AuthorizedOfficialTelephone: | 7075760818 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 49-02 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
ID | Type | State | Issuer | Description | 3631909 | 01 | CA | EDD STATE PROVIDER | OTHER | RS0249664 | 01 | CA | DEA | OTHER | ZS0249444A | 01 | CA | DEA | OTHER | CA-10228-M | 01 |   | CSAT (SAMHSA) | OTHER | 49-02 | 01 | CA | DHCS NTP | OTHER | 49AC | 05 | CA |   | MEDICAID |