Provider Demographics
NPI:1538279195
Name:CALIFORNIA STATE UNIVERSITY, SACRAMENTO STUDENT HEALTH CENTER
Entity Type:Organization
Organization Name:CALIFORNIA STATE UNIVERSITY, SACRAMENTO STUDENT HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STUDENT HEALTH CENTER, DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN,MHA
Authorized Official - Phone:916-278-6049
Mailing Address - Street 1:6000 J STREET
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-6049
Mailing Address - Country:US
Mailing Address - Phone:916-275-6035
Mailing Address - Fax:916-278-7359
Practice Address - Street 1:6000 J STREET
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-6049
Practice Address - Country:US
Practice Address - Phone:916-275-6035
Practice Address - Fax:916-278-7359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB64016FMedicaid