Healthcare Provider Details

I. General information

NPI: 1881974244
Provider Name (Legal Business Name): SOUTHWESTEN OKLAHOMA STATE UNIVERSITY TRAINING ROOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAMPUS DR
WEATHERFORD OK
73096-3001
US

IV. Provider business mailing address

PO BOX 819020
DALLAS TX
75381-9020
US

V. Phone/Fax

Practice location:
  • Phone: 972-687-1893
  • Fax:
Mailing address:
  • Phone: 972-687-1893
  • 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: EDWIN DETWEILER
Title or Position: HEAD ATHLETIC TRAINER
Credential: MA, ATC, LAT, PTA
Phone: 580-774-3073