Healthcare Provider Details

I. General information

NPI: 1417044801
Provider Name (Legal Business Name): PETER J MARINCOVICH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 03/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SONOMA AVE SUITE 316
SANTA ROSA CA
95405-4819
US

IV. Provider business mailing address

1111 SONOMA AVE SUITE 316
SANTA ROSA CA
95405-4819
US

V. Phone/Fax

Practice location:
  • Phone: 707-523-4740
  • Fax: 707-523-0231
Mailing address:
  • Phone: 707-523-4740
  • Fax: 707-523-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU758
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberHA1949
License Number StateCA

VIII. Authorized Official

Name: PETER JANSEN MARINCOVICH
Title or Position: OWNER AUDIOLOGIST
Credential: PHD AUDIOLOGIST DISP
Phone: 707-523-4740