Provider Demographics
NPI:1992475032
Name:REGENTS OF THE UNIV OF CALIFORNIA
Entity type:Organization
Organization Name:REGENTS OF THE UNIV OF CALIFORNIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:LEHR
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-794-8627
Mailing Address - Street 1:757 WESTWOOD PLZ
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-8358
Mailing Address - Country:US
Mailing Address - Phone:310-297-9308
Mailing Address - Fax:
Practice Address - Street 1:1131 WILSHIRE BLVD.
Practice Address - Street 2:SUITE 202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:424-259-7705
Practice Address - Fax:310-260-0105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-20
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1427055839Medicaid