Provider Demographics
NPI:1720467962
Name:BOUCH MEDICAL CORPORATION
Entity type:Organization
Organization Name:BOUCH MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUMMER
Authorized Official - Middle Name:
Authorized Official - Last Name:BEGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-861-7300
Mailing Address - Street 1:435 PETALUMA AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4273
Mailing Address - Country:US
Mailing Address - Phone:707-861-7300
Mailing Address - Fax:707-823-8568
Practice Address - Street 1:435 PETALUMA AVE STE 150
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4273
Practice Address - Country:US
Practice Address - Phone:707-861-7300
Practice Address - Fax:707-823-8568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA393692163WG0000X
CA20A9470204D00000X
CAG55518207R00000X
CAG35969208D00000X
CAND-353208D00000X
CAND-613208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty