Healthcare Provider Details

I. General information

NPI: 1629452255
Provider Name (Legal Business Name): COLORADO MESA UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 NORTH AVE
GRAND JUNCTION CO
81501-3122
US

IV. Provider business mailing address

PO BOX 650850 DEPT 1011
DALLAS TX
75265-0850
US

V. Phone/Fax

Practice location:
  • Phone: 970-248-1809
  • Fax: 972-367-3452
Mailing address:
  • Phone: 800-555-9073
  • Fax: 972-367-3452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MOUZON BASS III
Title or Position: AGENT
Credential:
Phone: 972-367-4845