Healthcare Provider Details

I. General information

NPI: 1467818633
Provider Name (Legal Business Name): MARIN BRAIN INJURY NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 MAGNOLIA AVE
LARKSPUR CA
94939-1019
US

IV. Provider business mailing address

1132 MAGNOLIA AVE
LARKSPUR CA
94939-1019
US

V. Phone/Fax

Practice location:
  • Phone: 415-461-6771
  • Fax: 415-461-8406
Mailing address:
  • Phone: 415-461-6771
  • Fax: 415-461-8406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA GILL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 415-461-6771