Healthcare Provider Details

I. General information

NPI: 1558503433
Provider Name (Legal Business Name): CENTRAL METHODIST UNIVERSITY SPORTS MEDICINE/ATHLETIC TRAINING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 03/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CENTRAL METHODIST SQ
FAYETTE MO
65248-1104
US

IV. Provider business mailing address

411 CENTRAL METHODIST SQ
FAYETTE MO
65248-1104
US

V. Phone/Fax

Practice location:
  • Phone: 660-248-6217
  • Fax: 660-248-6381
Mailing address:
  • Phone: 660-248-6217
  • Fax: 660-248-6381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number102437
License Number StateMO

VIII. Authorized Official

Name: MR. WADE WELTON
Title or Position: DIRECTOR,SPORTS MED/ATH TRAINING
Credential: ATC
Phone: 660-248-6217