Provider Demographics
NPI:1275658148
Name:MARIN PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:MARIN PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:415-499-0278
Mailing Address - Street 1:165 NORTH REDWOOD DRIVE
Mailing Address - Street 2:SUITE #120
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903
Mailing Address - Country:US
Mailing Address - Phone:415-499-0278
Mailing Address - Fax:
Practice Address - Street 1:165 N REDWOOD DR
Practice Address - Street 2:SUITE #120
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1969
Practice Address - Country:US
Practice Address - Phone:415-499-0278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15707174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31680ZMedicare ID - Type UnspecifiedGROUP NUMBER
CADC6851Medicare PIN