Healthcare Provider Details

I. General information

NPI: 1417651183
Provider Name (Legal Business Name): NORTHWEST COLLEGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 W 6TH ST BLDG 1
POWELL WY
82435-1898
US

IV. Provider business mailing address

15305 DALLAS PKWY STE 800
ADDISON TX
75001-6415
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MOUZON BASS III
Title or Position: ADMINISTRATOR
Credential:
Phone: 972-367-4845