1124021738 NPI number — MARIN COMMUNITY CLINIC

Table of content: (NPI 1124021738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124021738 NPI number — MARIN COMMUNITY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIN COMMUNITY CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124021738
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 PROFESSIONAL CENTER DR
Provider Second Line Business Mailing Address:
STE 311
Provider Business Mailing Address City Name:
NOVATO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94947-4334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-448-1531
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 BON AIR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENBRAE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94904-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-448-1500
Provider Business Practice Location Address Fax Number:
415-461-4229
Provider Enumeration Date:
05/27/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NAVARRO
Authorized Official First Name:
TYRONE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
415-448-1531

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  1100366 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FHC11975 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1100366 . This is a "DHS LICENSE - GREENBRAE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".