Healthcare Provider Details

I. General information

NPI: 1730467648
Provider Name (Legal Business Name): DELTA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 W SUNFLOWER RD
CLEVELAND MS
38733-0001
US

IV. Provider business mailing address

1003 W SUNFLOWER RD
CLEVELAND MS
38733-0001
US

V. Phone/Fax

Practice location:
  • Phone: 662-846-4280
  • Fax:
Mailing address:
  • Phone: 166-284-6428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name: ABBY HAVARD
Title or Position: ASSISTANT AD/HEALTH & PERFROMANCE
Credential: LAT
Phone: 662-846-4280