Organization
AGEWELL PACE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DERRICK WHITACRE (EXECUTIVE DIRECTOR)
(707) 615-4437
Entity
Organization
Contact information
Practice address
5789 STATE FARM DR STE 110, ROHNERT PARK, CA 94928-6308
(707) 615-4437
(707) 615-6955
Mailing address
5789 STATE FARM DR STE 110, ROHNERT PARK, CA 94928-6308
(707) 615-4437
(707) 615-6955
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
—
—
208D00000X
General Practice Physician
Primary
—
—
261Q00000X
Clinic/Center
—
—
Other
Enumeration date
06/09/2023
Last updated
06/09/2023
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