Provider Demographics
NPI:1538652003
Name:MARIN ADVANCED WOUND CENTER PC
Entity Type:Organization
Organization Name:MARIN ADVANCED WOUND CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:REYZELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:925-336-6062
Mailing Address - Street 1:165 ROWLAND WAY STE 208
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-5055
Mailing Address - Country:US
Mailing Address - Phone:415-680-0871
Mailing Address - Fax:800-808-1779
Practice Address - Street 1:165 ROWLAND WAY STE 208
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5055
Practice Address - Country:US
Practice Address - Phone:415-680-0871
Practice Address - Fax:800-808-1779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-10
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59522261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center