| 1370 In Custody Program | |
|
2777 Ventura Ave Santa Rosa CA 95403-2226 | |
| (707) 565-1492 | |
| Not Available |
| Full Name | 1370 In Custody Program |
|---|---|
| Speciality | Clinic/center - Mental Health (including Community Mental Health Center) |
| Location | 2777 Ventura Ave, Santa Rosa, California |
| Authorized Official Name and Position | Diana Stornetta (SUPERVISING ACCOUNTANT) |
| Authorized Official Contact | 7075654833 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| 1370 In Custody Program 2777 Ventura Ave Santa Rosa CA 95403-2226 Ph: (707) 565-1492 | 1370 In Custody Program 2777 Ventura Ave Santa Rosa CA 95403-2226 Ph: (707) 565-1492 |
| NPI Number | 1164820874 |
|---|---|
| Provider Enumeration Date | 12/11/2014 |
| Last Update Date | 01/16/2015 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1164820874 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
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