Healthcare Provider Details

I. General information

NPI: 1952731408
Provider Name (Legal Business Name): ALABAMA A&M UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MERIDIAN STREE
NORMAL AL
35762
US

IV. Provider business mailing address

PO BOX 1597
NORMAL AL
35762-1597
US

V. Phone/Fax

Practice location:
  • Phone: 256-372-4001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSIE ZUCNICK-KIMBUGWE
Title or Position: DIRECTOR OF SPORTS MEDICINE
Credential:
Phone: 256-372-8458