Provider Demographics
NPI:1386795011
Name:PENINSULA BIOMEDICAL, INC.
Entity type:Organization
Organization Name:PENINSULA BIOMEDICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNDEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAFNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-430-9066
Mailing Address - Street 1:PO BOX 66149
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95067-6149
Mailing Address - Country:US
Mailing Address - Phone:831-430-9066
Mailing Address - Fax:831-430-9068
Practice Address - Street 1:108 WHISPERING PINES DR
Practice Address - Street 2:SUITE 115
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4792
Practice Address - Country:US
Practice Address - Phone:831-430-9066
Practice Address - Fax:831-430-9068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CA2676332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4549517Medicaid
WI82712600Medicaid
OH2107491Medicaid
CO29401372Medicaid
MN8129631-00Medicaid
WA9048612Medicaid
VA9102475Medicaid
ID807375000Medicaid
IL=========001Medicaid
VA9102475Medicaid
ID807375000Medicaid