Healthcare Provider Details

I. General information

NPI: 1427021765
Provider Name (Legal Business Name): MISSOURI STATE UNIVERSITY ATHLETIC TRAINING SERVICESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S NATIONAL AVE
SPRINGFIELD MO
65804-0027
US

IV. Provider business mailing address

901 S NATIONAL AVE
SPRINGFIELD MO
65804-0027
US

V. Phone/Fax

Practice location:
  • Phone: 417-836-5461
  • Fax: 417-836-6101
Mailing address:
  • Phone: 417-836-5461
  • Fax: 417-836-6101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: MR. IVAN EUGENE MILTON
Title or Position: DIRECTOR ATHLETIC TRAINING SERVICES
Credential: A.T.
Phone: 417-836-5461