Healthcare Provider Details

I. General information

NPI: 1366733222
Provider Name (Legal Business Name): WESTERN KENTUCKY UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 COLLEGE HEIGHTS BLVD
BOWLING GREEN KY
42101-1000
US

IV. Provider business mailing address

1906 COLLEGE HEIGHTS BLVD
BOWLING GREEN KY
42101-1000
US

V. Phone/Fax

Practice location:
  • Phone: 270-745-6026
  • 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: BILLY EDWARDS
Title or Position: DIRECTOR OF SPORTS MEDICINE
Credential:
Phone: 270-745-6026