Provider Demographics
NPI:1750442653
Name:CALIFORNIA POLYTECHNIC STATE UNIVERSITY AT SAN LUIS OBISPO
Entity Type:Organization
Organization Name:CALIFORNIA POLYTECHNIC STATE UNIVERSITY AT SAN LUIS OBISPO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:805-756-1211
Mailing Address - Street 1:CAL POLY STATE UNIVERSITY HEALTH SERVICES
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93407
Mailing Address - Country:US
Mailing Address - Phone:805-756-1211
Mailing Address - Fax:805-745-5298
Practice Address - Street 1:CAL POLY HEALTH SERVICES
Practice Address - Street 2:GRAND AVE.
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93407
Practice Address - Country:US
Practice Address - Phone:805-756-1211
Practice Address - Fax:805-756-5298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 358948261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center