Basic Information
Provider Information
NPI: 1326444647
EntityType: 2
ReplacementNPI:  
OrganizationName: MARIN MEDICAL LABORATORIES
LastName:  
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Mailing Information
Address1: 1615 HILL RD STE B
Address2:  
City: NOVATO
State: CA
PostalCode: 949474338
CountryCode: US
TelephoneNumber: 4158987649
FaxNumber: 4158980870
Practice Location
Address1: 1165 MONTGOMERY DR
Address2:  
City: SANTA ROSA
State: CA
PostalCode: 954054801
CountryCode: US
TelephoneNumber: 7075255352
FaxNumber: 7075221535
Other Information
ProviderEnumerationDate: 11/13/2014
LastUpdateDate: 08/11/2022
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: PRASAD
AuthorizedOfficialFirstName: KEDAR
AuthorizedOfficialMiddleName: CHE
AuthorizedOfficialTitleorPosition: PATHOLOGIST
AuthorizedOfficialTelephone: 4152096983
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate: 08/11/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207ZP0102XCLF 00001292CAY193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology

No ID Information.


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