Healthcare Provider Details

I. General information

NPI: 1982739918
Provider Name (Legal Business Name): COMMUNITY COLLEGE DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PHELAN AVE
SAN FRANCISCO CA
94112-1821
US

IV. Provider business mailing address

50 PHELAN AVE
SAN FRANCISCO CA
94112-1821
US

V. Phone/Fax

Practice location:
  • Phone: 415-241-2229
  • Fax:
Mailing address:
  • Phone: 415-241-2229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number170344
License Number StateCA

VIII. Authorized Official

Name: MR. PETER GOLDSTEIN
Title or Position: VVCE CHANCELLOR OF ADMINISTRATION
Credential:
Phone: 415-241-2229