Basic Information
| Provider Information | |||||||||
| NPI: | 1851463723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UCLA PHARM & NM PRACTICE GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 3103018751 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MEDICAL PLZ | ||||||||
| Address2: | SUITE B114 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900958344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107949513 | ||||||||
| FaxNumber: | 3102672538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | WANG | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CAO | ||||||||
| AuthorizedOfficialTelephone: | 3102671188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0903X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | In Vivo & In Vitro Nuclear Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0059610 | 05 | CA | MEDICAID |