Provider Demographics
NPI:1184909947
Name:CALIFORNIA BAPTIST UNIVERSITY
Entity type:Organization
Organization Name:CALIFORNIA BAPTIST UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SISEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-552-8137
Mailing Address - Street 1:2900 ADAMS ST STE C10
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-7915
Mailing Address - Country:US
Mailing Address - Phone:423-316-2305
Mailing Address - Fax:
Practice Address - Street 1:2900 ADAMS ST STE C10
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-7915
Practice Address - Country:US
Practice Address - Phone:951-552-8137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health