MEDICARE: REGENTS OF THE UNIVERSITY OF CALIFORNIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174503767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGENTS OF THE UNIVERSITY OF CALIFORNIA

Provider Business Mailing Address
First Line	:	10850 WHITE ROCK RD
Second Line	:
City	:	RANCHO CORDOVA
State	:	CA
Zip	:	95670-6044
Country	:	US
Telephone Number	:	916-734-9255
Fax Number	:	916-451-8494

Provider Business Practice Location Address
First Line	:	1370 PRAIRIE CITY RD
Second Line	:
City	:	FOLSOM
State	:	CA
Zip	:	95630-9554
Country	:	US
Telephone Number	:	916-985-9320
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	ALLEN D HALL
Credential	:
Telephone Number	:	916-734-8203

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	10/09/2023

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