Healthcare Provider Details

I. General information

NPI: 1366041469
Provider Name (Legal Business Name): THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4343 LANKERSHIM BLVD STE 210
NORTH HOLLYWOOD CA
91602-2705
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 818-843-9038
  • Fax:
Mailing address:
  • Phone: 310-301-5256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BROOKE SOUHRADA
Title or Position: DIRECTOR
Credential:
Phone: 661-255-2420