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1255 N Dutton Ave Santa Rosa CA 95401-4663 | |
| (707) 546-9400 | |
| (707) 546-9464 |
| Full Name | |
|---|---|
| Speciality | Family Medicine |
| Location | 1255 N Dutton Ave, Santa Rosa, California |
| Authorized Official Name and Position | Ty Preston Affleck (PRESIDENT) |
| Authorized Official Contact | 7075469400 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1255 N Dutton Ave Santa Rosa CA 95401-4663 Ph: (707) 546-9400 | 1255 N Dutton Ave Santa Rosa CA 95401-4663 Ph: (707) 546-9400 |
| NPI Number | 1952555740 |
|---|---|
| Provider Enumeration Date | 11/06/2008 |
| Last Update Date | 10/13/2014 |
| Medicare PECOS PAC ID | 9032273453 |
|---|---|
| Medicare Enrollment ID | O20090130000131 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1952555740 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207QS0010X | Family Medicine - Sports Medicine | G073843 (California) | Primary |
| Provider Name | Ty Affleck |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1306941083 PECOS PAC ID: 8224192646 Enrollment ID: I20090130000124 |
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