MEDICARE: HUMBOLDT STATE UNIVERSITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS1000X	Student Health Clinic/Center		CA

General Provider Information

NPI Number	:	1104991744
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUMBOLDT STATE UNIVERSITY

Provider Business Mailing Address
First Line	:	1 HARPST ST
Second Line	:	BUILDING 42
City	:	ARCATA
State	:	CA
Zip	:	95521-8222
Country	:	US
Telephone Number	:	707-826-5019
Fax Number	:	707-826-5042

Provider Business Practice Location Address
First Line	:	1 HARPST ST
Second Line	:	BUILDING 42
City	:	ARCATA
State	:	CA
Zip	:	95521-8222
Country	:	US
Telephone Number	:	707-826-5019
Fax Number	:	707-826-5042

Authorized Official
Title or Position	:	ASSOCIATE DIRECTOR
Name	:	MRS. MARY G. VANCOTT
Credential	:
Telephone Number	:	707-826-5019

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	08/15/2008

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Directions to “HUMBOLDT STATE UNIVERSITY ” Practice Location

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