Provider Demographics
NPI:1447435912
Name:CAL POLY HEALTH SERVICES
Entity type:Organization
Organization Name:CAL POLY HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR HEALTH AND COUNSELING SERV
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:805-756-5278
Mailing Address - Street 1:1 GRAND AVE BUILDING 27
Mailing Address - Street 2:CAL POLY STATE UNIVERSITY
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93407-0000
Mailing Address - Country:US
Mailing Address - Phone:805-756-1211
Mailing Address - Fax:805-756-5298
Practice Address - Street 1:1 GRAND AVE BUILDING 27
Practice Address - Street 2:CAL POLY STATE UNIVERSITY
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93407-0000
Practice Address - Country:US
Practice Address - Phone:805-756-1211
Practice Address - Fax:805-756-5298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA397046261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center