Provider Demographics
NPI:1942573555
Name:MARIN HEALTHCARE DISTRICT
Entity Type:Organization
Organization Name:MARIN HEALTHCARE DISTRICT
Other - Org Name:SOLUNA SAUSALITO HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMANICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-464-2090
Mailing Address - Street 1:100 DRAKES LANDING RD # B
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2404
Mailing Address - Country:US
Mailing Address - Phone:415-464-2090
Mailing Address - Fax:415-464-2094
Practice Address - Street 1:111 SECOND ST
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-2526
Practice Address - Country:US
Practice Address - Phone:415-332-2600
Practice Address - Fax:415-332-2610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACS440AOtherMEDICARE GROUP PTAN