Provider Demographics
NPI:1528195393
Name:CALIFORNIA STATE UNIVERSITY STANISLAUS
Entity Type:Organization
Organization Name:CALIFORNIA STATE UNIVERSITY STANISLAUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STUDENT HEALTH CENTER DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-667-3396
Mailing Address - Street 1:1 UNIVERSITY CIR
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-3200
Mailing Address - Country:US
Mailing Address - Phone:209-667-3396
Mailing Address - Fax:209-667-3195
Practice Address - Street 1:1 UNIVERSITY CIR
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-3200
Practice Address - Country:US
Practice Address - Phone:209-667-3396
Practice Address - Fax:209-667-3195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLE11473336C0002X
CAPHE195953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy