Healthcare Provider Details

I. General information

NPI: 1104002146
Provider Name (Legal Business Name): AZUSA PACIFIC UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2008
Last Update Date: 01/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 E ALOSTA AVE
AZUSA CA
91702-2709
US

IV. Provider business mailing address

901 E ALOSTA AVE
AZUSA CA
91702-2701
US

V. Phone/Fax

Practice location:
  • Phone: 626-815-5421
  • Fax:
Mailing address:
  • Phone: 626-815-5421
  • Fax: 626-815-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK DICKERSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 626-387-5763