Provider Demographics
NPI:1861824518
Name:CALIFORNIA STATE UNIVERSITY LONG BEACH
Entity Type:Organization
Organization Name:CALIFORNIA STATE UNIVERSITY LONG BEACH
Other - Org Name:PT@THEBEACH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BUENAVENTURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-985-8286
Mailing Address - Street 1:1250 N BELLFLOWER BLVD
Mailing Address - Street 2:KIN-105
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90840-0004
Mailing Address - Country:US
Mailing Address - Phone:562-985-8286
Mailing Address - Fax:
Practice Address - Street 1:1250 N BELLFLOWER BLVD
Practice Address - Street 2:KIN-105
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90840-0004
Practice Address - Country:US
Practice Address - Phone:562-985-8286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALIFORNIA STATE UNIVERSITY LONG BEACH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-05
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty