Healthcare Provider Details

I. General information

NPI: 1063706406
Provider Name (Legal Business Name): LANGSTON UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 HIGHWAY 33 EAST C.F. GAYLES FIELDHOUSE ROOM 161
LANGSTON OK
73050
US

IV. Provider business mailing address

PO BOX 819020
DALLAS TX
75381-9020
US

V. Phone/Fax

Practice location:
  • Phone: 405-466-2961
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRETT WALDON
Title or Position: HEAD ATHLETIC TRAINER
Credential: ATC
Phone: 405-466-2961