Provider Demographics
NPI:1154503399
Name:MARIN COMMUNITY CLINIC
Entity Type:Organization
Organization Name:MARIN COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PATIENT ACCOUNTS
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:UDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-798-3106
Mailing Address - Street 1:9 COMMERCIAL BLVD
Mailing Address - Street 2:SUITE103
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6118
Mailing Address - Country:US
Mailing Address - Phone:415-448-1500
Mailing Address - Fax:415-798-3180
Practice Address - Street 1:3110 KERNER BLVD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-5411
Practice Address - Country:US
Practice Address - Phone:415-526-8500
Practice Address - Fax:415-526-8553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA051131Medicare Oscar/Certification
CA051131Medicare PIN