Petaluma Health Center, Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Petaluma, CA
NPI 1801655873 · NPPES record last updated Apr 22, 2024
Key facts
- NPI
- 1801655873
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- PETALUMA HEALTH CENTER, INC
- Practice address
- 500 Vallejo St
Petaluma, CA 94952-3364 - Phone
- (707) 559-7500
- NPI assigned
- Mar 13, 2024
- Organization subpart
- No
Authorized official
- Name
- Molly Jouaneh
- Title
- Cfo
- Phone
- (707) 559-7500
Owners & managing parties with NPI records 1
-
Nurit Licht, M.D.
Other NPIs with the same Medicare PAC ID 7
Corporate family (same tax ID) 11
Practitioners 76
-
Amy Adams, M.D.
-
Andrew Burns Ashcroft, M.D.
-
Leesa Benenhaley, FNP
-
Edward Bocc, PHYSICIAN ASSISTANT
-
Yolanda Basoco Briscoe, PSYD
-
Samantha Leigh Cardozo, M.S.
-
Laura Carter, OD, MPH
-
Carolyn Ruth Chase, RN, NP
-
Iun-Iu A. Chen, D.O.
-
Carlin Li-an CHI, M.D.
-
Jonathan Y Choe, M.D.
-
Julie D Clark, MD
-
Jesus Dimas-Arriaga, REGISTERED DIETITIAN
-
Paige Ely, DO
-
Laura E Fannon, PSYD INTERN
-
Erika Gary, RN, MSN-FNP
-
Jay W. Goldberg, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
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
- Corporation · Non-profit
- Enrollment address
- 500 Vallejo St
Petaluma, CA 94952-3364
All disclosed owners & managing parties 10
| Name | Role | Since | Share |
|---|---|---|---|
| Molly Lauren Jouaneh |
Corporate Officer |
Jan 6, 2020 | 5% |
| W-2 Managing Employee |
Jan 6, 2020 | 5% | |
| Roberto Ramirez |
Corporate Officer |
Jul 1, 2021 | 5% |
| Corporate Director |
Jul 1, 2021 | 5% | |
| Teresa Taylor-King |
Corporate Director |
Jul 1, 2021 | 5% |
| Catherine West |
Corporate Director |
Jul 1, 2021 | 5% |
| William Barrett |
Corporate Director |
Jul 1, 2021 | 5% |
| Phoebe Ellis |
Corporate Director |
Jul 1, 2021 | 5% |
| Thomas Isaak |
Corporate Director |
Jul 1, 2021 | 5% |
| Pedro Toledo |
Corporate Officer |
Aug 3, 2015 | 5% |
| W-2 Managing Employee |
Aug 3, 2015 | 5% | |
| Elizabeth Goldblatt |
Corporate Director |
Jul 1, 2021 | 5% |
| Nurit Licht |
Corporate Officer |
Aug 3, 2015 | 5% |
| W-2 Managing Employee |
Aug 29, 2005 | 5% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20241218003552 | CA | Part a Provider - Federally Qualified Health Center (FQHC) | 9133180375 | Practice locations: Petaluma, CA |
National Provider Directory
- Tax ID family
- Petaluma Health Center Inc
Locations
500 Vallejo St
Petaluma, CA 94952
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
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
- San Antonio High School Health Clinic
- San Antonio High School-Based Health Center
Other providers in Petaluma, CA
- Petaluma Family Therapy Inc
- Petaluma Health Center Inc
- Petaluma Health Center, Inc
- Petaluma Health Center, Inc
- Petaluma Health Center, Inc
- Petaluma Health Center, Inc
- Petaluma Health Center, Inc.
- Petaluma Healthcare & Wellness Centre, LP
- Petaluma People Services Center
- Petaluma People Services Center
All providers in Petaluma, 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 Apr 22, 2024. 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.