1477892099 NPI number — MARIN MAGNETIC RESONANCE IMAGING CENTER, LLC

Table of content: (NPI 1477892099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477892099 NPI number — MARIN MAGNETIC RESONANCE IMAGING CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIN MAGNETIC RESONANCE IMAGING CENTER, LLC
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:
6
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:
1477892099
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVATO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94948-6102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-884-3404
Provider Business Mailing Address Fax Number:
415-883-3406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1260 S ELISEO DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GREENBRAE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94904-2009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-461-9033
Provider Business Practice Location Address Fax Number:
415-883-0877
Provider Enumeration Date:
02/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BELICK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
415-884-3096

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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