Provider Demographics
NPI:1962650820
Name:CALIFORNIA STATE UNIVERSITY AT LONG BEACH
Entity Type:Organization
Organization Name:CALIFORNIA STATE UNIVERSITY AT LONG BEACH
Other - Org Name:CSULB STUDENT HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR STUDENT HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:CARBUTO
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:562-985-2208
Mailing Address - Street 1:1250 BELFLOWER BLVD
Mailing Address - Street 2:STUDENT HEALTH SERVICES
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90840-0201
Mailing Address - Country:US
Mailing Address - Phone:562-985-2208
Mailing Address - Fax:562-985-8404
Practice Address - Street 1:1250 N BELLFLOWER BLVD
Practice Address - Street 2:STUDENT HEALTH SERVICES
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90840-0004
Practice Address - Country:US
Practice Address - Phone:562-985-2208
Practice Address - Fax:562-985-8404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN/A261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR009803OtherMEDICAL GROUP NUMBER
CA4003036Medicare PIN