=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952100943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARLEE-I MYSTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2025
-----------------------------------------------------
Last Update Date | 10/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 849 JAMESTOWN AVE UNIT 301
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94124-3781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-787-2637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 849 JAMESTOWN AVE UNIT 301
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94124-3781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MILDRED KING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-787-2637
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 282J00000X
-----------------------------------------------------
Taxonomy Name | Religious Nonmedical Health Care Institution
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 374J00000X
-----------------------------------------------------
Taxonomy Name | Doula
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------