Provider Demographics
NPI:1013176775
Name:PHYSICAL MEDICINE CTR OF MARIN, A PT CORP.
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE CTR OF MARIN, A PT CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:IACOVELLI
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DC
Authorized Official - Phone:415-380-9242
Mailing Address - Street 1:33 MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-1903
Mailing Address - Country:US
Mailing Address - Phone:415-380-9242
Mailing Address - Fax:415-388-7458
Practice Address - Street 1:33 MILLER AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-1903
Practice Address - Country:US
Practice Address - Phone:415-380-9242
Practice Address - Fax:415-388-7458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty