Provider Demographics
NPI:1457888299
Name:MARIN CITY HEALTH AND WELLNESS CENTER
Entity type:Organization
Organization Name:MARIN CITY HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAYVON
Authorized Official - Middle Name:
Authorized Official - Last Name:MUHAMMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-339-8813
Mailing Address - Street 1:630 DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-1107
Mailing Address - Country:US
Mailing Address - Phone:415-339-8813
Mailing Address - Fax:
Practice Address - Street 1:880 LAS GALLINAS AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903
Practice Address - Country:US
Practice Address - Phone:415-339-8813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55000861261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)