Provider Demographics
NPI:1275526329
Name:REGENTS OF THE UNIVERSITY OF CA
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF CA
Other - Org Name:UCD NUTRITIONAL ASSESMENT LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-734-9129
Mailing Address - Street 1:4900 BROADWAY
Mailing Address - Street 2:STE 2500
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-1532
Mailing Address - Country:US
Mailing Address - Phone:916-734-9200
Mailing Address - Fax:916-734-9336
Practice Address - Street 1:TB 156
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616
Practice Address - Country:US
Practice Address - Phone:530-752-2714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB58715FMedicaid
CALAB58715FMedicaid