Healthcare Provider Details

I. General information

NPI: 1942573555
Provider Name (Legal Business Name): MARIN HEALTHCARE DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2012
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SECOND ST
SAUSALITO CA
94965-2526
US

IV. Provider business mailing address

100 DRAKES LANDING RD # B SUITE 250
GREENBRAE CA
94904-2404
US

V. Phone/Fax

Practice location:
  • Phone: 415-332-2600
  • Fax: 415-332-2610
Mailing address:
  • Phone: 415-464-2090
  • Fax: 415-464-2094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LEE DOMANICO
Title or Position: CEO
Credential:
Phone: 415-464-2090