NPIMap

Organization Active NPI

Petaluma Health Center Inc

Doing business as Point Reyes Medical Clinic

  • Federally Qualified Health Center (FQHC)
  • Point Reyes Station, CA
National Provider Identifier
1053420844
Registry record updated Jun 8, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
110000399 Issued in CA
Legal business name
PETALUMA HEALTH CENTER INC
Doing business as
Point Reyes Medical Clinic
Practice address
3 Sixth Street
Point Reyes Station, CA 94956-0910
Phone
(415) 663-8666
Fax
(415) 663-9532
NPI assigned
Aug 29, 2006
Last updated
Jun 8, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 8, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Molly Jouaneh
Title
Cfo
Phone
(707) 559-7500

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 110000399 CA Primary

Addresses

Primary practice location

3 Sixth Street
Point Reyes Station, CA 94956-0910

Mailing address

1455 N McDowell Blvd Ste D
Petaluma, CA 94954-6503
Phone (707) 559-7500

Other identifiers 4

IdentifierTypeStateIssuer
EAP70434FMedicaidCA
BCP70434FMedicaidCA
HAP70434FMedicaidCA
FHC70434FMedicaidCA

Other names 1

  • Point Reyes Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200827001659 CA Part A Provider - Federally Qualified Health Center (FQHC) 9133180375 1 other NPI on this enrollment
Practice locations: Point Reyes Station, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1053420844. Details of each certification follow.

Federally qualified health center certification: CCN 551911

Legal name
PETALUMA HEALTH CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 3, 2002
Last certification
Oct 3, 2002
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 16, 1999 in CA
Enrollment address
3 Sixth St
Point Reyes Station, CA 94956

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0674680Point Reyes Medical Clinic3 Sixth St, Point Reyes Station, CA 94956Provider-performed microscopyFeb 14, 2027

National Provider Directory

National Provider Directory
Tax ID family
Petaluma Health Center Inc12 organizations share this tax ID, including this one

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Fernando Carrillo Individual Corporate DirectorBoard Member Jan 1, 2023 5%
Molly Lauren Jouaneh Individual Corporate Officer Jan 6, 2020
W-2 Managing Employee Jan 6, 2020
Darlene Sandoval Individual Corporate DirectorBoard Member Mar 1, 2025 5%
Roberto Ramirez Individual Corporate Director May 31, 2016
Teresa Taylor-King Individual Corporate DirectorBoard Member Oct 1, 2017 5%
Catherine West Individual Corporate Director Sep 25, 2018
Mariana Guerrero Individual Corporate DirectorBoard Member Mar 1, 2025 5%
William Barrett Individual Corporate DirectorBoard Member Jan 1, 2026 5%
Phoebe Ellis Individual Corporate Director Jun 25, 2019 5%
Thomas Isaak Individual Corporate DirectorBoard Member Feb 23, 2016
Pedro Toledo Individual Corporate Officer Aug 3, 2015
Corporate Director Aug 3, 2015
W-2 Managing Employee Aug 3, 2015
Elizabeth Goldblatt Individual Corporate DirectorBoard Member Jan 1, 2026 5%
Anne Mirante Individual Corporate DirectorBoard Member Oct 1, 2023 5%

Change-of-ownership history 2

DateEventCounterparty
Jul 1, 2020 Change of OwnershipThis provider was the buyer Point Reyes Medical ClinicCCN 551911, CA, NPI 1053420844
Jul 1, 2020 Change of OwnershipThis provider was the seller Petaluma Health Center IncCCN 551911, CA, NPI 1053420844

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156809600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1623110400000",
    "number": "1053420844",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1455 N MCDOWELL BLVD STE D",
            "city": "PETALUMA",
            "state": "CA",
            "postal_code": "949546503",
            "telephone_number": "707-559-7500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3 SIXTH STREET",
            "city": "POINT REYES STATION",
            "state": "CA",
            "postal_code": "949560910",
            "telephone_number": "415-663-8666",
            "fax_number": "415-663-9532"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETALUMA HEALTH CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-29",
        "last_updated": "2021-06-08",
        "certification_date": "2021-06-08",
        "status": "A",
        "authorized_official_last_name": "JOUANEH",
        "authorized_official_first_name": "MOLLY",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "707-559-7500"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "110000399",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "EAP70434F",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "BCP70434F",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "HAP70434F",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC70434F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Point Reyes Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Point Reyes Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Point Reyes Station, CA

Sources for this page

Verify at the official NPI Registry.