Provider Demographics
NPI:1295022556
Name:UNIVERSITY OF NORTHERN CALIFORNIA
Entity Type:Organization
Organization Name:UNIVERSITY OF NORTHERN CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YOUNG KING
Authorized Official - Middle Name:
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:PH D, LAC
Authorized Official - Phone:707-636-5960
Mailing Address - Street 1:1300 VALLEY HOUSE DR
Mailing Address - Street 2:SUITE 100-27
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-4927
Mailing Address - Country:US
Mailing Address - Phone:707-664-6365
Mailing Address - Fax:
Practice Address - Street 1:1300 VALLEY HOUSE DR
Practice Address - Street 2:SUITE 100-27
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-4927
Practice Address - Country:US
Practice Address - Phone:707-664-6365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 737302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization