Provider Demographics
NPI:1437377421
Name:MARIN TREATMENT CENTER
Entity Type:Organization
Organization Name:MARIN TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:415-457-3755
Mailing Address - Street 1:1466 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2021
Mailing Address - Country:US
Mailing Address - Phone:415-457-3755
Mailing Address - Fax:415-457-9516
Practice Address - Street 1:1466 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2021
Practice Address - Country:US
Practice Address - Phone:415-457-3755
Practice Address - Fax:415-457-9516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21-70261QM2800X
CA110000417261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR11863FMedicaid
CACMM70602FMedicaid
CA00G265381Medicaid
CAEAP70602FMedicaid
CA00G265381Medicare PIN