Healthcare Provider Details

I. General information

NPI: 1184909947
Provider Name (Legal Business Name): CALIFORNIA BAPTIST UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 ADAMS ST STE C10
RIVERSIDE CA
92504-7915
US

IV. Provider business mailing address

2900 ADAMS ST STE C10
RIVERSIDE CA
92504-7915
US

V. Phone/Fax

Practice location:
  • Phone: 951-552-8137
  • Fax:
Mailing address:
  • Phone: 423-316-2305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY A SISEMORE
Title or Position: CLINIC DIRECTOR
Credential:
Phone: 951-552-8137