MEDICARE: MARIN COMMUNITY CLINIC

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	261QF0400X	Federally Qualified Health Center (FQHC)	1100491	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1100491	OTHER	CA	DHS LICENSE- NOVATO
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790788107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIN COMMUNITY CLINIC

Provider Business Mailing Address
First Line	:	9 COMMERCIAL BLVD
Second Line	:	SUITE 103
City	:	NOVATO
State	:	CA
Zip	:	94949
Country	:	US
Telephone Number	:	415-798-3106
Fax Number	:	415-798-3180

Provider Business Practice Location Address
First Line	:	400 PROFESSIONAL CENTER DR
Second Line	:	STE 424
City	:	NOVATO
State	:	CA
Zip	:	94947-4368
Country	:	US
Telephone Number	:	415-448-1531
Fax Number	:	415-892-8732

Authorized Official
Title or Position	:	DIRECTOR OF PATIENT ACCOUNTS
Name	:	MS. DEBORAH UDALL
Credential	:
Telephone Number	:	415-798-3106

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	01/28/2016

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Directions to “MARIN COMMUNITY CLINIC ” Practice Location

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