Provider Demographics
NPI:1124167382
Name:SOUTHERN CALIFORNIA UNIVERSITY-SOMA
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA UNIVERSITY-SOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACADEMIC DEAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:HYUNSOOK
Authorized Official - Last Name:CHO
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:213-413-9500
Mailing Address - Street 1:3460 WILSHIRE BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2223
Mailing Address - Country:US
Mailing Address - Phone:213-413-9500
Mailing Address - Fax:213-413-5400
Practice Address - Street 1:3460 WILSHIRE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2223
Practice Address - Country:US
Practice Address - Phone:213-413-9500
Practice Address - Fax:213-413-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC4924171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGAC000360Medicaid
CA0831136Medicaid