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General NPI Number Information
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NPI Number | 1730463258
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Entity Type | Organization
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Legal Business Name | PRIMA MEDICAL GROUP-TERRA LINDA
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Dates
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Enumeration Date | 10/03/2011
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Last Update Date | 08/14/2012
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Provider Practice Location Address
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Address Line | 4000 CIVIC CENTER DRIVE SUITE 200B
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City | SAN RAFAEL
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State | CA
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Zip | 94903
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Country | US
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Telephone | 415-492-3333
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Fax | 415-492-3425
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Provider Business Mailing Address
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Address Line | 4 HAMILTON LANDING SUITE 100
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City | NOVATO
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State | CA
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Zip | 94949
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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 | MR. JOEL A CRISTE
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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 | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | G55637
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | G73451
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License Number State | CA
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