Healthcare Provider Details

I. General information

NPI: 1487020640
Provider Name (Legal Business Name): BUSHNELL UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 E 11TH AVE
EUGENE OR
97401-3745
US

IV. Provider business mailing address

5050 SPRING VALLEY RD
DALLAS TX
75244-3995
US

V. Phone/Fax

Practice location:
  • Phone: 541-684-7351
  • Fax: 972-367-3451
Mailing address:
  • Phone: 972-367-4845
  • Fax: 972-367-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

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