Healthcare Provider Details

I. General information

NPI: 1730463258
Provider Name (Legal Business Name): PRIMA MEDICAL GROUP-TERRA LINDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CIVIC CENTER DRIVE SUITE 200B
SAN RAFAEL CA
94903
US

IV. Provider business mailing address

4 HAMILTON LANDING SUITE 100
NOVATO CA
94949
US

V. Phone/Fax

Practice location:
  • Phone: 415-492-3333
  • Fax: 415-492-3425
Mailing address:
  • Phone: 415-884-1840
  • Fax: 415-884-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG73451
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberG55637
License Number StateCA

VIII. Authorized Official

Name: MR. JOEL A CRISTE
Title or Position: CEO
Credential:
Phone: 415-884-1840