Provider Demographics
NPI:1710672001
Name:MARIN FUNCTIONAL MEDICINE
Entity Type:Organization
Organization Name:MARIN FUNCTIONAL MEDICINE
Other - Org Name:MARIN FUNCTIONAL NUTRITION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL NUTRITIONIST / HEALTH COAC
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, NBC-HWC
Authorized Official - Phone:415-846-1891
Mailing Address - Street 1:22 JULES DR
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-2015
Mailing Address - Country:US
Mailing Address - Phone:415-846-1891
Mailing Address - Fax:
Practice Address - Street 1:22 JULES DR
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-2015
Practice Address - Country:US
Practice Address - Phone:415-846-1891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-11
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty