=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881727220
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF SOUTHERN CALIFORNIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 09/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1321 NORTH MISSION ROAD LRB 207 AND 208
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-224-5590
-----------------------------------------------------
Fax | 323-225-4035
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 513199
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90051-1199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-224-5590
-----------------------------------------------------
Fax | 323-225-4035
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR VP ADMINISTRATION
-----------------------------------------------------
Name | TODD DICKEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-740-8184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 05D1033782
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------