Healthcare Provider Details

I. General information

NPI: 1437377421
Provider Name (Legal Business Name): MARIN TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1466 LINCOLN AVE
SAN RAFAEL CA
94901-2021
US

IV. Provider business mailing address

1466 LINCOLN AVE
SAN RAFAEL CA
94901-2021
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-3755
  • Fax: 415-457-9516
Mailing address:
  • Phone: 415-457-3755
  • Fax: 415-457-9516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number21-70
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number110000417
License Number StateCA

VIII. Authorized Official

Name: MR. JONATHAN FONG
Title or Position: ASSOCIATE DIRECTOR
Credential: MBA
Phone: 415-457-3755