Basic Information
| Provider Information | |||||||||
| NPI: | 1811217946 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMA MEDICAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 HAMILTON LANDING | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158841840 | ||||||||
| FaxNumber: | 4158843510 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 HAMILTON LANDING | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158841840 | ||||||||
| FaxNumber: | 4158843510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2010 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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| AuthorizedOfficialLastName: | CRISTE | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4158841840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIMA MEDICAL FOUNDATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.