NPIMap

Organization Active NPI

Petaluma Health Center Inc

Doing business as Rohnert Park Health Center

  • Federally Qualified Health Center (FQHC)
  • Rohnert Park, CA
National Provider Identifier
1669870739
Registry record updated Mar 24, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
110000313 Issued in CA
Legal business name
PETALUMA HEALTH CENTER INC
Doing business as
Rohnert Park Health Center
Practice address
5900 State Farm Dr
Rohnert Park, CA 94928-2149
Phone
(707) 559-7500
Fax
(707) 559-7620
NPI assigned
Dec 5, 2014
Last updated
Mar 24, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 24, 2022

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

Authorized official

Name
Mr. Pedro Toledo
Title
Interim Ceo
Phone
(707) 559-7692

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 110000313 CA Primary

Addresses

Primary practice location

5900 State Farm Dr
Rohnert Park, CA 94928-2149

Mailing address

1179 N McDowell Blvd
Petaluma, CA 94954-6559

Other names 1

  • Rohnert Park Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050315000415 CA Part B Supplier - Clinic/Group Practice 9133180375 Receives reassigned benefits from 70 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Petaluma, CA; Rohnert Park, CA
O20160330002260 CA Part A Provider - Federally Qualified Health Center (FQHC) 9133180375 Practice locations: Rohnert Park, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669870739. Details of each certification follow.

Federally qualified health center certification: CCN 751848

Legal name
PETALUMA HEALTH CENTER INC
Doing business as
ROHNERT PARK HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 26, 2016
Last certification
Apr 26, 2016
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
Mar 15, 2005 in CA
Enrollment address
5900 State Farm Dr
Ste 200
Rohnert Park, CA 94928-2149

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.

National Provider Directory

National Provider Directory
Tax ID family
Petaluma Health Center12 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 12

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

NameRoleSinceShare
Molly Lauren Jouaneh Individual Corporate OfficerChief Financial Office Jan 1, 2020 5%
Marc a Pounds Individual Corporate DirectorBoard of Directors Treasurer Mar 27, 2013
Kathryn Powell Individual Corporate OfficerCeo Jun 23, 2003 20%
W-2 Managing EmployeeCeo Jan 29, 2016 20%
Joseph Tambe Individual Corporate DirectorBoard Member Aug 1, 2012
Onita P Pellegrini Individual Corporate DirectorBoard Member Feb 26, 2014
Glennon Timothy Moran Individual Corporate OfficerCfo Sep 22, 2008 20%
W-2 Managing EmployeeCfo Jan 29, 2016 20%
Pedro Toledo Individual Corporate OfficerCao Mar 10, 2014 20%
W-2 Managing EmployeeCao Jan 29, 2016 20%
Nurit Licht Individual Corporate OfficerCmo Jan 1, 2014 20%
W-2 Managing EmployeeChief Medical Officer Jan 29, 2016 20%
Patricia G Padilla-Noah Individual Corporate DirectorBoard Member Oct 28, 2014
Georgina Warmoth Individual Corporate DirectorBoard Member Aug 1, 2012
Mary E Celestre Individual Corporate DirectorBoard Member Mar 27, 2013
Anthony D Sarno Individual Corporate DirectorPresident Board of Directors Oct 26, 2011

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 91

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.

View all 91

NPI Registry JSON

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

{
    "created_epoch": "1417737600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1648080000000",
    "number": "1669870739",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1179 N MCDOWELL BLVD",
            "city": "PETALUMA",
            "state": "CA",
            "postal_code": "949546559"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5900 STATE FARM DR",
            "city": "ROHNERT PARK",
            "state": "CA",
            "postal_code": "949282149",
            "telephone_number": "707-559-7500",
            "fax_number": "707-559-7620"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETALUMA HEALTH CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-05",
        "last_updated": "2022-03-24",
        "certification_date": "2022-03-24",
        "status": "A",
        "authorized_official_last_name": "TOLEDO",
        "authorized_official_first_name": "PEDRO",
        "authorized_official_title_or_position": "INTERIM CEO",
        "authorized_official_telephone_number": "707-559-7692",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "110000313",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Rohnert Park Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Rohnert Park Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rohnert Park, CA

Sources for this page

Verify at the official NPI Registry.