Healthcare Provider Details

I. General information

NPI: 1154388577
Provider Name (Legal Business Name): SPORT & SPINE THERAPY OF MARIN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 GREENFIELD AVE
SAN ANSELMO CA
94960-2416
US

IV. Provider business mailing address

220 GREENFIELD AVE
SAN ANSELMO CA
94960-2416
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-4454
  • Fax: 415-457-4944
Mailing address:
  • Phone: 415-457-4454
  • Fax: 415-457-4944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BOBBY ISMAIL
Title or Position: PRESIDENT
Credential:
Phone: 209-353-1988