1174503767 NPI number — REGENTS OF THE UNIVERSITY OF CALIFORNIA

Table of content: (NPI 1174503767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174503767 NPI number — REGENTS OF THE UNIVERSITY OF CALIFORNIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REGENTS OF THE UNIVERSITY OF CALIFORNIA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UC DAVIS MEDICAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174503767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1370 PRAIRIE CITY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLSOM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95630-9554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-985-9320
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/19/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0081521 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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