Healthcare Provider Details

I. General information

NPI: 1942348958
Provider Name (Legal Business Name): CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/17/2014
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: 818-677-7732
Mailing address:
  • Phone: 818-677-3671
  • Fax: 818-677-7732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHE19585
License Number StateCA

VIII. Authorized Official

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