Provider Demographics
NPI:1417495623
Name:BAYSIDE MARIN, INC.
Entity Type:Organization
Organization Name:BAYSIDE MARIN, INC.
Other - Org Name:BAYSIDE MARIN OUTPATIENT
Other - Org Type:Other Name
Authorized Official - Title/Position:VP AND SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-861-6000
Mailing Address - Street 1:718 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3213
Mailing Address - Country:US
Mailing Address - Phone:415-450-0031
Mailing Address - Fax:
Practice Address - Street 1:718 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3213
Practice Address - Country:US
Practice Address - Phone:415-450-0031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210030CP261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder