Healthcare Provider Details

I. General information

NPI: 1710672001
Provider Name (Legal Business Name): MARIN FUNCTIONAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 JULES DR
NOVATO CA
94947-2015
US

IV. Provider business mailing address

22 JULES DR
NOVATO CA
94947-2015
US

V. Phone/Fax

Practice location:
  • Phone: 415-846-1891
  • Fax:
Mailing address:
  • Phone: 415-846-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIANE ROBINSON
Title or Position: OWNER, CLINICAL NUTRITIONIST
Credential: MS, CDN, NBC-HWC
Phone: 415-846-1891