Provider Demographics
NPI:1932327343
Name:MARIN COMMUNITY CLINIC
Entity Type:Organization
Organization Name:MARIN COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL STAFF COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-448-1579
Mailing Address - Street 1:6090 REDWOOD BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-4569
Mailing Address - Country:US
Mailing Address - Phone:415-448-1500
Mailing Address - Fax:415-798-3180
Practice Address - Street 1:250 BON AIR RD
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1702
Practice Address - Country:US
Practice Address - Phone:415-448-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCP11975FMedicaid