Provider Demographics
NPI:1104002146
Name:AZUSA PACIFIC UNIVERSITY
Entity Type:Organization
Organization Name:AZUSA PACIFIC UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-387-5763
Mailing Address - Street 1:901 E ALOSTA AVE
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2701
Mailing Address - Country:US
Mailing Address - Phone:626-815-5421
Mailing Address - Fax:626-815-5015
Practice Address - Street 1:918 E ALOSTA AVE
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-2709
Practice Address - Country:US
Practice Address - Phone:626-815-5421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-19
Last Update Date:2008-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency