Organization
PETALUMA ICF DDH INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RICHARD ALBERT HIRE (LICENSEE)
(707) 894-3686
Entity
Organization
Contact information
Practice address
805 PETALUMA AVE, SONOMA, CA 95476
(707) 938-9195
(707) 939-3519
Mailing address
226 MERCED DRIVE, SAN BRUNO, CA 94066
(650) 872-3438
(650) 872-6738
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
—
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
55G416
MEDI CAL
CA
Enumeration date
12/21/2006
Last updated
08/22/2020
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