Healthcare Provider Details

I. General information

NPI: 1255529236
Provider Name (Legal Business Name): REGENTS OF THE UNIVERSITY OF CA.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8110 LAGUNA BLVD
ELK GROVE CA
95758-7904
US

IV. Provider business mailing address

4900 BROADWAY STE 1200
SACRAMENTO CA
95820-1535
US

V. Phone/Fax

Practice location:
  • Phone: 916-683-3955
  • Fax: 916-736-1419
Mailing address:
  • Phone: 916-734-9255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE4735
License Number StateCA

VIII. Authorized Official

Name: ALLEN D HALL
Title or Position: CFO
Credential: M.D.
Phone: 916-734-9200