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General NPI Number Information
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NPI Number | 1760914782
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Entity Type | Organization
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Legal Business Name | CALIFORNIA STATE UNIVERSITY, LOS ANGELES
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Dates
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Enumeration Date | 03/29/2017
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Last Update Date | 03/29/2017
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Provider Practice Location Address
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Address Line | 5151 STATE UNIVERSITY DR
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City | LOS ANGELES
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State | CA
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Zip | 90032-4226
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Country | US
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Telephone | 972-367-4845
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Fax |
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Provider Business Mailing Address
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Address Line | 5050 SPRING VALLEY RD.
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City | DALLAS
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State | TX
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Zip | 75244-3909
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | AGENT
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Name | MOUZON BASS
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Credential |
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Telephone | 972-367-4845
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 18176
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License Number State | CA
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