Healthcare Provider Details

I. General information

NPI: 1063727048
Provider Name (Legal Business Name): STEPHEN F AUSTIN STATE UNIVERSITY SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1936 NORTH ST SFA SPORTS MEDICINE CLINIC
NACOGDOCHES TX
75965-3940
US

IV. Provider business mailing address

1936 NORTH ST SFA SPORTS MEDICINE CLINIC
NACOGDOCHES TX
75965-3940
US

V. Phone/Fax

Practice location:
  • Phone: 936-468-4550
  • Fax: 936-468-4052
Mailing address:
  • Phone: 936-468-4550
  • Fax: 936-468-4052

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: SANDY MILLER
Title or Position: ASST AD FOR SPORTS MEDICINE
Credential: ATC
Phone: 936-468-4550