Healthcare Provider Details

I. General information

NPI: 1902813744
Provider Name (Legal Business Name): CALIFORNIA STATE UNIVERSITY, NORTHRIDGE, KLOTZ STUDENT HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18111 NORDHOFF ST
NORTHRIDGE CA
91330-8270
US

IV. Provider business mailing address

18111 NORDHOFF ST
NORTHRIDGE CA
91330-8270
US

V. Phone/Fax

Practice location:
  • Phone: 818-677-3666
  • Fax: 818-677-5225
Mailing address:
  • Phone: 818-677-3666
  • Fax: 818-677-5225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License NumberGOVERNMENT ENTITY
License Number StateCA

VIII. Authorized Official

Name: MS. YOLANDA REID CHASSIAKOS
Title or Position: DIRECTOR, STUDENT HEALTH CENTER
Credential: M.D.
Phone: 818-677-3666