Healthcare Provider Details

I. General information

NPI: 1699809236
Provider Name (Legal Business Name): FLORIDA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 LEARNING WAY
TALLAHASSEE FL
32306-4178
US

IV. Provider business mailing address

960 LEARNING WAY
TALLAHASSEE FL
32306-4178
US

V. Phone/Fax

Practice location:
  • Phone: 850-644-1802
  • Fax: 850-644-4251
Mailing address:
  • Phone: 850-644-1802
  • Fax: 850-644-4251

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: MR. SCOTT OTTE
Title or Position: CFO
Credential:
Phone: 850-645-6992