Healthcare Provider Details

I. General information

NPI: 1508244641
Provider Name (Legal Business Name): CENTRAL STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 05/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BRUSH ROW RD
WILBERFORCE OH
45384-5800
US

IV. Provider business mailing address

PO BOX 650850
DALLAS TX
75265-0850
US

V. Phone/Fax

Practice location:
  • Phone: 937-925-3748
  • Fax: 972-367-3451
Mailing address:
  • Phone: 972-367-4845
  • Fax: 972-367-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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