Provider Demographics
NPI:1720070071
Name:NORTHBAY HEALTHCARE GROUP
Entity type:Organization
Organization Name:NORTHBAY HEALTHCARE GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HOSPICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:RYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-646-4095
Mailing Address - Street 1:4500 BUSINESS CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-6888
Mailing Address - Country:US
Mailing Address - Phone:707-646-3595
Mailing Address - Fax:707-646-3577
Practice Address - Street 1:1101 B.GALE WILSON BLVD
Practice Address - Street 2:SUITE 101A
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533
Practice Address - Country:US
Practice Address - Phone:707-646-3595
Practice Address - Fax:707-646-3577
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHBAY HEALTHCARE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-22
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550009228OtherDEPARTMENT OF PUBLIC HEALTH LICENSE
CAHPC01651FMedicaid