Provider Demographics
NPI:1760534713
Name:NORTHBAY HEALTHCARE GROUP
Entity type:Organization
Organization Name:NORTHBAY HEALTHCARE GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AVP, MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:JAYE LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-646-3289
Mailing Address - Street 1:1000 NUT TREE RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4100
Mailing Address - Country:US
Mailing Address - Phone:707-646-3401
Mailing Address - Fax:707-646-4803
Practice Address - Street 1:421 NUT TREE RD
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-3508
Practice Address - Country:US
Practice Address - Phone:707-646-5500
Practice Address - Fax:707-624-7501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHBAY HEALTHCARE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-18
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X, 261QU0200X
CA110000093282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0093240OtherMEDI-CAL PHYSICIAN GROUP
CA110000093OtherDHS LICENSE
CAGR0093240Medicaid
CA110000093OtherDHS LICENSE
CAGR0093240Medicaid