Healthcare Provider Details

I. General information

NPI: 1518207612
Provider Name (Legal Business Name): KENNESAW STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 04/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CHASTAIN RD NW MD5200 HOUSE 52
KENNESAW GA
30144-5588
US

IV. Provider business mailing address

1000 CHASTAIN RD NW MD5200 HOUSE 52
KENNESAW GA
30144-5588
US

V. Phone/Fax

Practice location:
  • Phone: 770-423-6644
  • Fax: 770-499-3655
Mailing address:
  • Phone: 770-423-6644
  • Fax: 770-499-3655

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: ERIN WOLFE
Title or Position: PROCUREMENT MANAGER
Credential:
Phone: 770-420-4355