1730205154 NPI number — CALIFORNIA STATE UNIVERSITY SAN BERNARDINO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730205154 NPI number — CALIFORNIA STATE UNIVERSITY SAN BERNARDINO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALIFORNIA STATE UNIVERSITY SAN BERNARDINO
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:
Provider Other Organization Name Type Code:
6
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:
1730205154
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
37500 COOK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM DESERT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92211-2900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-289-2965
Provider Business Mailing Address Fax Number:
909-537-7027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5500 UNIVERSITY PKWY
Provider Second Line Business Practice Location Address:
STUDENT HEALTH CENTER
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92407-2318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-537-3295
Provider Business Practice Location Address Fax Number:
909-537-7027
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JAWORSKI
Authorized Official First Name:
BETH
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
909-537-3070

Provider Taxonomy Codes

  • Taxonomy code: 261QS1000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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