Provider Demographics
NPI:1871731729
Name:REGENTS OF THE UNIVERSITY OF
Entity type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-794-8627
Mailing Address - Street 1:10920 WILSHIRE BLVD
Mailing Address - Street 2:STE 1600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6502
Mailing Address - Country:US
Mailing Address - Phone:310-794-8299
Mailing Address - Fax:310-794-6790
Practice Address - Street 1:14250 ARMINTA ST
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-6871
Practice Address - Country:US
Practice Address - Phone:818-989-6610
Practice Address - Fax:818-989-6775
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-30
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0919331291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0919331OtherCLIA
CADG289AMedicare PIN