| Name | Value |
|---|---|
| PROVIDER TYPE | Ambulatory Health Care Facilities |
| CLASSIFICATION | Clinic/Center |
| AREA OF SPECIALIZATION | Student Health |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-08-30 00:00:00 |
| VA CODE | V115500 |
| X12 CODE | 261QS1000X |
| INDIVIDUAL/NON | NON-INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5296124 |
| EFFECTIVE DATE/TIME |
|