Basic Information
| Provider Information | |||||||||
| NPI: | 1912091018 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARIN COMMUNITY CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 COMMERCIAL BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949496118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154481500 | ||||||||
| FaxNumber: | 4157983180 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 BON AIR RD | ||||||||
| Address2: | |||||||||
| City: | LARKSPUR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949391143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154481500 | ||||||||
| FaxNumber: | 4154617334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 01/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | UDALL | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PATIENT ACCOUNTS | ||||||||
| AuthorizedOfficialTelephone: | 4157983106 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 110000366 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC11975 | 05 | CA | MEDICAID |