Provider Demographics
NPI:1962687269
Name:MT. SAN ANTONIO COLLEGE
Entity Type:Organization
Organization Name:MT. SAN ANTONIO COLLEGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, STUDENT HEALTH SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPLES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:909-594-5611
Mailing Address - Street 1:1100 N GRAND AVE
Mailing Address - Street 2:67B
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-1341
Mailing Address - Country:US
Mailing Address - Phone:909-591-5611
Mailing Address - Fax:909-468-3997
Practice Address - Street 1:1100 N GRAND AVE
Practice Address - Street 2:67B
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-1341
Practice Address - Country:US
Practice Address - Phone:909-594-5611
Practice Address - Fax:909-468-3997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health