Petaluma Icf DDH Inc

Primary specialty

Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X

Legal business name

PETALUMA ICF DDH INC

Practice address

805 Petaluma Ave
Sonoma, CA 95476

Phone

(707) 938-9195

Fax

(707) 939-3519

NPI assigned

Dec 21, 2006

Organization subpart

No

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

Authorized official

Name

Mr. Richard Albert Hire

Title

Licensee

Phone

(707) 894-3686

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1265596373. Details of each certification follow.

• CCN 55G416 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 55G416

Legal name

PETALUMA ICF/DDH

Certification status

Active

Provider type (POS)

Intermediate care facility for individuals with intellectual disabilities

Participating since

Feb 19, 2002

Last certification

Mar 1, 2024

Beds

8

Ownership / control type

Other (specify)

Facility address

805 Petaluma Avenue
Sonoma, CA 95476

Locations

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

{
    "created_epoch": "1166659200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1265596373",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "226 MERCED DRIVE",
            "city": "SAN BRUNO",
            "state": "CA",
            "postal_code": "94066",
            "telephone_number": "650-872-3438",
            "fax_number": "650-872-6738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "805 PETALUMA AVE",
            "city": "SONOMA",
            "state": "CA",
            "postal_code": "95476",
            "telephone_number": "707-938-9195",
            "fax_number": "707-939-3519"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETALUMA ICF DDH INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-21",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "HIRE",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_middle_name": "ALBERT",
        "authorized_official_title_or_position": "LICENSEE",
        "authorized_official_telephone_number": "707-894-3686",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "CA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDI CAL",
            "identifier": "55G416",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Robert A Pack, DDS
• Neal Atul Patel, DDS
• Jenny Tobriner Perez
• Scott Vernon Perryman, M.D.
• Personal Hearing Solutions (Kenwood Hearing Centers)
• Petaluma Valley Internal Medicine Inc
• Carole Marie Petersen, LCSW
• Charles Robert Pettit, M.D.
• Robert T Petty, DO
• Pharmaca Integrative Pharmacy, Inc.

• Intellectual Disabilities Intermediate Care Facility in Sonoma, CA
• Providers in Sonoma, CA by specialty
• Intellectual Disabilities Intermediate Care Facility in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.