=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780910471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGENTS OF THE UNIVERSITY OF CALIFORNIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2009
-----------------------------------------------------
Last Update Date | 03/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8929 UNIVERSITY CENTER LANE SUITE 201
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-657-6028
-----------------------------------------------------
Fax | 858-550-9032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9500 GILMAN DRIVE MC0878
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92093-0878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-657-6028
-----------------------------------------------------
Fax | 858-550-9032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | LORI DONALDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-543-6613
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------