Provider Demographics
NPI:1902244528
Name:PRIMA MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:PRIMA MEDICAL FOUNDATION
Other - Org Name:PRIMA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MONDRAGON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-884-1840
Mailing Address - Street 1:4 HAMILTON LNDG
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-8256
Mailing Address - Country:US
Mailing Address - Phone:415-884-1840
Mailing Address - Fax:415-883-7127
Practice Address - Street 1:652 PETALUMA AVE
Practice Address - Street 2:SUITE H
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4256
Practice Address - Country:US
Practice Address - Phone:707-823-7616
Practice Address - Fax:707-823-2803
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMA MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty