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General NPI Number Information
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NPI Number | 1063161156
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Entity Type | Organization
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Legal Business Name | CHRISTIAN BROTHERS UNIVERSITY
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Dates
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Enumeration Date | 03/23/2022
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Last Update Date | 03/23/2022
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Provider Practice Location Address
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Address Line | 650 E PARKWAY S
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City | MEMPHIS
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State | TN
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Zip | 38104-5519
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Country | US
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Telephone | 972-367-4845
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Fax |
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Provider Business Mailing Address
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Address Line | 15305 DALLAS PKWY STE 800
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City | ADDISON
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State | TX
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Zip | 75001-6415
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Country | US
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Telephone | 972-367-4845
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR/AGENT
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Name | MR. MOUZON BASS
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Credential |
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Telephone | 972-367-4845
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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