1942573555 NPI number — MARIN HEALTHCARE DISTRICT

Table of content: (NPI 1942573555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942573555 NPI number — MARIN HEALTHCARE DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIN HEALTHCARE DISTRICT
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:
SOLUNA SAUSALITO HEALTH CENTER
Provider Other Organization Name Type Code:
5
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:
1942573555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 DRAKES LANDING RD # B
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
GREENBRAE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94904-2404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-464-2090
Provider Business Mailing Address Fax Number:
415-464-2094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 SECOND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAUSALITO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94965-2526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-332-2600
Provider Business Practice Location Address Fax Number:
415-332-2610
Provider Enumeration Date:
02/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DOMANICO
Authorized Official First Name:
LEE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
415-464-2090

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CS440A . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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