NPIMap

Organization Active NPI

Petaluma Health Center, Inc

Doing business as San Antonio High School Health Clinic

  • Federally Qualified Health Center (FQHC)
  • Petaluma, CA
National Provider Identifier
1801655873
Registry record updated Apr 22, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PETALUMA HEALTH CENTER, INC
Doing business as
San Antonio High School Health Clinic
San Antonio High School-Based Health Center
Practice address
500 Vallejo St
Petaluma, CA 94952-3364
Phone
(707) 559-7500
NPI assigned
Mar 13, 2024
Last updated
Apr 22, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 22, 2024

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 Primary

Addresses

Primary practice location

500 Vallejo St
Petaluma, CA 94952-3364

Mailing address

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

Other names 2

  • San Antonio High School Health Clinic Doing business as
  • San Antonio High School-Based Health Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20241218003552 CA Part A Provider - Federally Qualified Health Center (FQHC) 9133180375 Practice locations: Petaluma, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1801655873. Details of each certification follow.

Federally qualified health center certification: CCN A01917

Legal name
PETALUMA HEALTH CENTER INC
Doing business as
SAN ANTONIO HIGH SCHOOL HEALTH CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 21, 2024
Last certification
Dec 21, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
500 Vallejo St
Petaluma, CA 94952-3364

Other NPIs with the same Medicare PAC ID 7

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

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.

Locations

500 Vallejo St
Petaluma, CA 94952

Ownership & related parties

All disclosed owners & managing parties 10

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 OfficerCfo Jan 6, 2020 5%
W-2 Managing EmployeeCfo Jan 6, 2020 5%
Roberto Ramirez Individual Corporate OfficerPresident Board of Directors Jul 1, 2021 5%
Corporate DirectorPresident Board of Directors Jul 1, 2021 5%
Teresa Taylor-King Individual Corporate DirectorMember Board of Directors Jul 1, 2021 5%
Catherine West Individual Corporate DirectorMember Board of Directors Jul 1, 2021 5%
William Barrett Individual Corporate DirectorMember Board of Directors Jul 1, 2021 5%
Phoebe Ellis Individual Corporate DirectorSecretary Board of Directors Jul 1, 2021 5%
Thomas Isaak Individual Corporate DirectorVice President Board of Directors Jul 1, 2021 5%
Pedro Toledo Individual Corporate OfficerCeo Aug 3, 2015 5%
W-2 Managing EmployeeCeo Aug 3, 2015 5%
Elizabeth Goldblatt Individual Corporate DirectorTreasurer Board of Directors Jul 1, 2021 5%
Nurit Licht Individual Corporate OfficerCmo Aug 3, 2015 5%
W-2 Managing EmployeeMD; Aug 29, 2005 5%

Owners & managing parties with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1710288000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1713744000000",
    "number": "1801655873",
    "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": "500 VALLEJO ST",
            "city": "PETALUMA",
            "state": "CA",
            "postal_code": "949523364",
            "telephone_number": "707-559-7500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETALUMA HEALTH CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-03-13",
        "last_updated": "2024-04-22",
        "certification_date": "2024-04-22",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "San Antonio High School Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "San Antonio High School-Based Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Petaluma, CA

Sources for this page

Verify at the official NPI Registry.