Healthcare Provider Details

I. General information

NPI: 1538652003
Provider Name (Legal Business Name): MARIN ADVANCED WOUND CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2018
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 ROWLAND WAY STE 208
NOVATO CA
94945-5055
US

IV. Provider business mailing address

165 ROWLAND WAY STE 208
NOVATO CA
94945-5055
US

V. Phone/Fax

Practice location:
  • Phone: 415-680-0871
  • Fax: 800-808-1779
Mailing address:
  • Phone: 415-680-0871
  • Fax: 800-808-1779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberG59522
License Number StateCA

VIII. Authorized Official

Name: ALEXANDER REYZELMAN
Title or Position: AUTHORIZED OFFICIAL
Credential: DPM
Phone: 925-336-6062