Basic Information
| Provider Information | |||||||||
| NPI: | 1770703886 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SRM ALLIANCE HOSPITAL SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PETALUMA VALLEY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1165 MONTGOMERY DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075255300 | ||||||||
| FaxNumber: | 7075255392 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N MCDOWELL BLVD | ||||||||
| Address2: | |||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949542339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077782631 | ||||||||
| FaxNumber: | 7077789117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICCIONI | ||||||||
| AuthorizedOfficialFirstName: | MICHEL | ||||||||
| AuthorizedOfficialMiddleName: | DANTE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7075255320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.