=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306057930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGENTS OF THE UNIVERSITY OF CA. DAVIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4860 Y ST SUITE 2100
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95817-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-734-8423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4860 Y ST SUITE 2100
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95817-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-734-8423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | DR. PHILLIP J RAIMONDI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 916-734-7945
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------