Basic Information
| Provider Information | |||||||||
| NPI: | 1639366586 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMA MEDICAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 HAMILTON LNDG | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949498256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158841840 | ||||||||
| FaxNumber: | 4158843510 | ||||||||
| Practice Location | |||||||||
| Address1: | 165 ROWLAND WAY STE 100 | ||||||||
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| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949455055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158984211 | ||||||||
| FaxNumber: | 4158989252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2007 | ||||||||
| LastUpdateDate: | 08/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | MONDRAGON | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4158841840 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | G30247 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.