Healthcare Provider Details

I. General information

NPI: 1114105327
Provider Name (Legal Business Name): WILLIAM WOODS UNIVERSITY ATHLETIC TRAINING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE UNIVERSITY AVE
FULTON MO
65251-2388
US

IV. Provider business mailing address

ONE UNIVERSITY AVE
FULTON MO
65251-2388
US

V. Phone/Fax

Practice location:
  • Phone: 573-592-4388
  • Fax: 573-592-4386
Mailing address:
  • Phone: 573-592-4388
  • Fax: 573-592-4386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2002005841
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. AMY E HAINES
Title or Position: HEAD ATHLETIC TRAINER
Credential: ATCL
Phone: 573-592-4388