Petaluma Health Center Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Rohnert Park, CA
NPI 1669870739 · NPPES record last updated Mar 24, 2022
Key facts
- NPI
- 1669870739
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- License
- 110000313 (CA)
- Legal business name
- PETALUMA HEALTH CENTER INC
- Practice address
- 5900 State Farm Dr
Rohnert Park, CA 94928-2149 - Phone
- (707) 559-7500
- Fax
- (707) 559-7620
- NPI assigned
- Dec 5, 2014
- Organization subpart
- No
Authorized official
- Name
- Mr. Pedro Toledo
- Title
- Interim Ceo
- Phone
- (707) 559-7692
Owners & managing parties with NPI records 2
-
Nurit Licht, M.D.
Other NPIs on the same Medicare enrollment 1
Other NPIs with the same Medicare PAC ID 7
Corporate family (same tax ID) 11
Practitioners 118
-
Iun-Iu A. Chen, D.O.
-
Karl Greer, MD
-
Mariana Harms, M.S., MFT
-
Erin Joy Helgerson, M.D.
-
Jessicca L Jarrett, FNP
-
Yimdriuska Magan Mendoza, MD, MPH
-
Sean Nadalin, PA
-
Danielle Oryn, D.O.
-
John Pendleton, M.D.
-
Christina Helena Pineda, N.P.
-
Hilary Powell, PA
-
Sean Upton, RN
-
Daniel L Wrightsman, MA, MFTI
-
James Jerome Wu, MD
-
Amy Adams, M.D.
-
Andrew Burns Ashcroft, M.D.
-
Leesa Benenhaley, FNP
-
Carolyn Ruth Chase, RN, NP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in CA
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
- Corporation · Non-profit
- Incorporated
- Mar 15, 2005 in CA
- Enrollment address
- 5900 State Farm Dr
Ste 200
Rohnert Park, CA 94928-2149
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Molly Lauren Jouaneh |
Corporate Officer |
Jan 1, 2020 | 5% |
| Marc a Pounds |
Corporate Director |
Mar 27, 2013 | |
| Kathryn Powell |
Corporate Officer |
Jun 23, 2003 | 20% |
| W-2 Managing Employee |
Jan 29, 2016 | 20% | |
| Joseph Tambe |
Corporate Director |
Aug 1, 2012 | |
| Onita P Pellegrini |
Corporate Director |
Feb 26, 2014 | |
| Glennon Timothy Moran |
Corporate Officer |
Sep 22, 2008 | 20% |
| W-2 Managing Employee |
Jan 29, 2016 | 20% | |
| Pedro Toledo |
Corporate Officer |
Mar 10, 2014 | 20% |
| W-2 Managing Employee |
Jan 29, 2016 | 20% | |
| Nurit Licht |
Corporate Officer |
Jan 1, 2014 | 20% |
| W-2 Managing Employee |
Jan 29, 2016 | 20% | |
| Patricia G Padilla-Noah |
Corporate Director |
Oct 28, 2014 | |
| Georgina Warmoth |
Corporate Director |
Aug 1, 2012 | |
| Mary E Celestre |
Corporate Director |
Mar 27, 2013 | |
| Anthony D Sarno |
Corporate Director |
Oct 26, 2011 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
- Tax ID family
- Petaluma Health Center Inc
Locations
5900 State Farm Dr
Rohnert Park, CA 94928
Phone (707) 206-3000
5900 State Farm Dr
Ste 200
Rohnert Park, CA 94928
Phone (707) 559-7600
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | 110000313 | CA | Yes |
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
- Rohnert Park Health Center
Other providers in Rohnert Park, CA
- Paula Shadid, O.D.
- Paula Pelavin
- Nicole Lynn Penney
- Ryan Pepin
- Emily Perez
- Petaluma Health Center, Inc
- Petaluma Health Center, Inc.
- Tanner Petersen
- Jennifer Lynn Peterson
- Brian Pham
All providers in Rohnert Park, CA · Federally Qualified Health Center (FQHC) in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 24, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.