Provider Demographics
NPI:1033410113
Name:CAL POLY UNIVERSITY
Entity Type:Organization
Organization Name:CAL POLY UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:VIERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-869-2760
Mailing Address - Street 1:3801 W TEMPLE AVE
Mailing Address - Street 2:#46
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2557
Mailing Address - Country:US
Mailing Address - Phone:909-869-4222
Mailing Address - Fax:909-869-2741
Practice Address - Street 1:3801 W TEMPLE AVE
Practice Address - Street 2:#46
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2557
Practice Address - Country:US
Practice Address - Phone:909-869-4222
Practice Address - Fax:909-869-4561
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STUDENT HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QOOOX261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service