=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205566544
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2022
-----------------------------------------------------
Last Update Date | 08/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 248 HAMPSHIRE RD STE 210
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91361-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-370-0040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5767 W CENTURY BLVD STE 400
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90045-5631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF ACCOUNTING
-----------------------------------------------------
Name | KATHERINE HALE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-301-5311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------