Provider Demographics
NPI:1487895975
Name:DREW HITTENBERGER
Entity type:Organization
Organization Name:DREW HITTENBERGER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DREW
Authorized Official - Middle Name:ARNOLD
Authorized Official - Last Name:HITTENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:CP BOC
Authorized Official - Phone:707-765-1122
Mailing Address - Street 1:1111 SONOMA AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4819
Mailing Address - Country:US
Mailing Address - Phone:707-765-1122
Mailing Address - Fax:707-765-4571
Practice Address - Street 1:181 LYNCH CREEK
Practice Address - Street 2:SUITE 101
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-765-1122
Practice Address - Fax:707-765-4571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECP 1093335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4129830001OtherPTAN PETALUMA
CA4129830006OtherPTAN SANTA ROSA
CA4129830007OtherPTAN KENTFIELD
CA4129830001OtherMEDICARE SUPPLIER NUMBER