1790788107 NPI number — MARIN COMMUNITY CLINIC

Table of content: (NPI 1790788107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790788107 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:
1790788107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 COMMERCIAL BLVD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
NOVATO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-798-3106
Provider Business Mailing Address Fax Number:
415-798-3180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 PROFESSIONAL CENTER DR
Provider Second Line Business Practice Location Address:
STE 424
Provider Business Practice Location Address City Name:
NOVATO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94947-4368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-448-1531
Provider Business Practice Location Address Fax Number:
415-892-8732
Provider Enumeration Date:
05/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
UDALL
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PATIENT ACCOUNTS
Authorized Official Telephone Number:
415-798-3106

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  1100491 , 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: 1100491 . This is a "DHS LICENSE- NOVATO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC70941 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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