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General NPI Number Information
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NPI Number | 1447435912
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Entity Type | Organization
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Legal Business Name | CAL POLY HEALTH SERVICES
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Dates
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Enumeration Date | 01/03/2008
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Last Update Date | 01/03/2008
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Provider Practice Location Address
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Address Line | 1 GRAND AVE BUILDING 27 CAL POLY STATE UNIVERSITY
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93407-0000
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Country | US
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Telephone | 805-756-1211
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Fax | 805-756-5298
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Provider Business Mailing Address
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Address Line | 1 GRAND AVE BUILDING 27 CAL POLY STATE UNIVERSITY
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93407-0000
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Country | US
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Telephone | 805-756-1211
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Fax | 805-756-5298
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Authorized Official
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Title or Position | DIRECTOR HEALTH AND COUNSELING SERV
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Name | DR. MARTIN E. BRAGG
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Credential | PHD
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Telephone | 805-756-5278
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 397046
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License Number State | CA
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