Provider Demographics
NPI:1831265933
Name:CSU SAN MARCOS STUDENT HEALTH SRV PHY
Entity type:Organization
Organization Name:CSU SAN MARCOS STUDENT HEALTH SRV PHY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-750-4920
Mailing Address - Street 1:333 S TWIN OAKS VALLEY RD BLDG 21
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92096-0001
Mailing Address - Country:US
Mailing Address - Phone:760-750-4021
Mailing Address - Fax:760-750-3181
Practice Address - Street 1:333 S TWIN OAKS VALLEY RD BLDG 21
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92096-0001
Practice Address - Country:US
Practice Address - Phone:760-750-4021
Practice Address - Fax:760-750-3181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHE532943336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1993413OtherPK