Healthcare Provider Details

I. General information

NPI: 1043850191
Provider Name (Legal Business Name): GLENVILLE STATE COLLEGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH ST
GLENVILLE WV
26351-1200
US

IV. Provider business mailing address

5050 SPRING VALLEY RD
DALLAS TX
75244-3995
US

V. Phone/Fax

Practice location:
  • Phone: 972-367-4845
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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