Provider Demographics
NPI:1558485896
Name:CALIFORNIA POLYTECHNIC STATE UNIVERSITY
Entity Type:Organization
Organization Name:CALIFORNIA POLYTECHNIC STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ATHLETIC TRAINER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:EGGEN
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:805-756-5491
Mailing Address - Street 1:13020 ATASCADERO RD
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-5902
Mailing Address - Country:US
Mailing Address - Phone:805-458-5193
Mailing Address - Fax:
Practice Address - Street 1:1 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93407-9000
Practice Address - Country:US
Practice Address - Phone:805-756-5491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty