Provider Demographics
NPI:1336493121
Name:CALIFORNIA STATE UNIVERSITY LOS ANGELES STUDENT HEALTH CENTER
Entity Type:Organization
Organization Name:CALIFORNIA STATE UNIVERSITY LOS ANGELES STUDENT HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH CARE PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:RAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:323-343-3300
Mailing Address - Street 1:5151 STATE UNIVERSITY DR
Mailing Address - Street 2:STUDENT HEALTH CENTER
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90032-4226
Mailing Address - Country:US
Mailing Address - Phone:323-343-3300
Mailing Address - Fax:323-343-6557
Practice Address - Street 1:5151 STATE UNIVERSITY DR
Practice Address - Street 2:STUDENT HEALTH CENTER
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90032-4226
Practice Address - Country:US
Practice Address - Phone:323-343-3300
Practice Address - Fax:323-343-6557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11108261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service