1760559447 NPI number — SONOMA DIABETIC SUPPLIES

Table of content: (NPI 1760559447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760559447 NPI number — SONOMA DIABETIC SUPPLIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SONOMA DIABETIC SUPPLIES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760559447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
246 PERKINS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SONOMA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95476-6954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-938-2667
Provider Business Mailing Address Fax Number:
707-938-5402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
246 PERKINS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SONOMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95476-6954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-938-2667
Provider Business Practice Location Address Fax Number:
707-938-5402
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FANUCCCHI
Authorized Official First Name:
SHEILA
Authorized Official Middle Name:
RAE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
707-938-2667

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  PHA462690 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PHA462690 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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