=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336493121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALIFORNIA STATE UNIVERSITY LOS ANGELES STUDENT HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2012
-----------------------------------------------------
Last Update Date | 11/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5151 STATE UNIVERSITY DR STUDENT HEALTH CENTER
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90032-4226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-343-3300
-----------------------------------------------------
Fax | 323-343-6557
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5151 STATE UNIVERSITY DR STUDENT HEALTH CENTER
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90032-4226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-343-3300
-----------------------------------------------------
Fax | 323-343-6557
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEALTH CARE PROVIDER
-----------------------------------------------------
Name | MS. RAYNE DAWSON
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 323-343-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | PA11108
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------