Provider Demographics
NPI:1912220781
Name:MARIN COMMUNITY CLINIC
Entity Type:Organization
Organization Name:MARIN COMMUNITY CLINIC
Other - Org Name:MARIN COMMUNITY CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DSW
Authorized Official - Phone:415-798-3107
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:415-798-3109
Mailing Address - Fax:415-798-3180
Practice Address - Street 1:6090 REDWOOD BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-4569
Practice Address - Country:US
Practice Address - Phone:415-798-3109
Practice Address - Fax:415-798-3180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)