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General NPI Number Information
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NPI Number | 1639366586
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Entity Type | Organization
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Legal Business Name | PRIMA MEDICAL FOUNDATION
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Dates
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Enumeration Date | 09/25/2007
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Last Update Date | 08/01/2012
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Provider Practice Location Address
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Address Line | 165 ROWLAND WAY STE 100
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City | NOVATO
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State | CA
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Zip | 94945-5055
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Country | US
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Telephone | 415-898-4211
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Fax | 415-898-9252
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Provider Business Mailing Address
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Address Line | 4 HAMILTON LNDG SUITE 100
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City | NOVATO
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State | CA
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Zip | 94949-8256
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Country | US
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Telephone | 415-884-1840
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Fax | 415-884-3510
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Authorized Official
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Title or Position | CEO
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Name | DENNIS MONDRAGON
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Credential |
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Telephone | 415-884-1840
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | G30247
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License Number State | CA
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