Provider Demographics
NPI:1043997273
Name:MARC D. KOMORI STAGER, PSYD FAMILY PSYCHOLOGY A PROFESSIONAL CORPORATI
Entity type:Organization
Organization Name:MARC D. KOMORI STAGER, PSYD FAMILY PSYCHOLOGY A PROFESSIONAL CORPORATI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:D
Authorized Official - Last Name:KOMORI STAGER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:925-325-5022
Mailing Address - Street 1:PO BOX 2203
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-5203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3375 PORT CHICAGO HWY STE 15
Practice Address - Street 2:UNIT #520
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520
Practice Address - Country:US
Practice Address - Phone:925-325-5022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)