Healthcare Provider Details

I. General information

NPI: 1790788107
Provider Name (Legal Business Name): MARIN COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 PROFESSIONAL CENTER DR STE 424
NOVATO CA
94947-4368
US

IV. Provider business mailing address

9 COMMERCIAL BLVD SUITE 103
NOVATO CA
94949
US

V. Phone/Fax

Practice location:
  • Phone: 415-448-1531
  • Fax: 415-892-8732
Mailing address:
  • Phone: 415-798-3106
  • Fax: 415-798-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number1100491
License Number StateCA

VIII. Authorized Official

Name: MS. DEBORAH UDALL
Title or Position: DIRECTOR OF PATIENT ACCOUNTS
Credential:
Phone: 415-798-3106