Provider Demographics
NPI:1326093626
Name:WELLBOUND OF SANTA ROSA LLC
Entity type:Organization
Organization Name:WELLBOUND OF SANTA ROSA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-736-2700
Mailing Address - Street 1:300 SANTANA ROW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2423
Mailing Address - Country:US
Mailing Address - Phone:707-541-3410
Mailing Address - Fax:650-625-6007
Practice Address - Street 1:2301 CIRCADIAN WAY
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5416
Practice Address - Country:US
Practice Address - Phone:707-541-3410
Practice Address - Fax:707-541-3415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLBOUND LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC52550FMedicaid
CA552550Medicare Oscar/Certification