Provider Demographics
NPI:1073648630
Name:SPECIALTY CARE AND SURGERY CENTER
Entity type:Organization
Organization Name:SPECIALTY CARE AND SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:R
Authorized Official - Last Name:DHANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-279-8733
Mailing Address - Street 1:5685 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-8945
Mailing Address - Country:US
Mailing Address - Phone:707-279-8733
Mailing Address - Fax:707-279-8731
Practice Address - Street 1:5685 MAIN ST
Practice Address - Street 2:
Practice Address - City:KELSEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95451-8945
Practice Address - Country:US
Practice Address - Phone:707-279-8733
Practice Address - Fax:707-279-8731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG6256207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G625260Medicaid
CA00G625260Medicaid
CAE04677Medicare UPIN