Healthcare Provider Details

I. General information

NPI: 1366111734
Provider Name (Legal Business Name): ANNA IRENE MARINCOVICH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 FARMERS LN STE 10
SANTA ROSA CA
95405-6718
US

IV. Provider business mailing address

795 FARMERS LN STE 10
SANTA ROSA CA
95405-6718
US

V. Phone/Fax

Practice location:
  • Phone: 707-571-7615
  • Fax: 707-571-8601
Mailing address:
  • Phone: 707-571-7615
  • Fax: 707-571-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: