Healthcare Provider Details

I. General information

NPI: 1730555400
Provider Name (Legal Business Name): SNOW COLLEGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E. COLLEGE WAY
EPHRAIM UT
84627
US

IV. Provider business mailing address

PO BOX 650850
DALLAS TX
75265-0850
US

V. Phone/Fax

Practice location:
  • Phone: 800-555-9073
  • Fax: 972-367-3452
Mailing address:
  • Phone: 972-367-4845
  • Fax: 972-367-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily 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: HANDY
Phone: 972-367-4845