Provider Demographics
NPI:1174885610
Name:BRENDT D. CARLSON, MD INC DBA MAR MONTE MEDICAL CLINIC
Entity type:Organization
Organization Name:BRENDT D. CARLSON, MD INC DBA MAR MONTE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALMA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-761-7225
Mailing Address - Street 1:846 FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-3814
Mailing Address - Country:US
Mailing Address - Phone:831-761-7225
Mailing Address - Fax:831-761-1178
Practice Address - Street 1:846 FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3814
Practice Address - Country:US
Practice Address - Phone:831-761-7225
Practice Address - Fax:831-761-1178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41986302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization