Healthcare Provider Details

I. General information

NPI: 1336680388
Provider Name (Legal Business Name): JOHNSON C. SMITH UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BEATTIES FORD RD
CHARLOTTE NC
28216-5302
US

IV. Provider business mailing address

5050 SPRING VALLEY RD.
DALLAS TX
75244-3909
US

V. Phone/Fax

Practice location:
  • Phone: 972-367-4845
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberNC200001254
License Number StateNC

VIII. Authorized Official

Name: MOUZON BASS III
Title or Position: AGENT
Credential:
Phone: 972-367-4845