Healthcare Provider Details

I. General information

NPI: 1508514902
Provider Name (Legal Business Name): MARIN COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 2ND ST
SAN RAFAEL CA
94901-2707
US

IV. Provider business mailing address

PO BOX 5008
NOVATO CA
94948-5008
US

V. Phone/Fax

Practice location:
  • Phone: 415-448-1500
  • Fax: 415-798-3104
Mailing address:
  • Phone: 415-448-1500
  • Fax: 415-798-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANDREA M SKELLY
Title or Position: BILLING MANAGER
Credential: CPC
Phone: 415-798-3135