MEDICARE: CITY OF SAN MARINO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	590004140	OTHER		RRB

General Provider Information

NPI Number	:	1003815507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF SAN MARINO

Provider Business Mailing Address
First Line	:	PO BOX 269110
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95826-9110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 HUNTINGTON DR
Second Line	:
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2639
Country	:	US
Telephone Number	:	626-300-0735
Fax Number	:

Authorized Official
Title or Position	:	FIRE CHIEF
Name	:	MARK DONDANVILLE
Credential	:
Telephone Number	:	626-222-1704

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	12/17/2019

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Directions to “CITY OF SAN MARINO ” Practice Location

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