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General NPI Number Information
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NPI Number | 1114361250
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Entity Type | Organization
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Legal Business Name | STEPHEN F. AUSTIN STATE UNIVERSITY
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Dates
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Enumeration Date | 04/19/2013
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Last Update Date | 04/19/2013
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Provider Practice Location Address
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Address Line | 2106 RAQUET ST
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City | NACOGDOCHES
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State | TX
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Zip | 75962-0001
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Country | US
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Telephone | 936-468-4006
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Fax |
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Provider Business Mailing Address
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Address Line | 2106 RAQUET ST PO BOX 13058 SFA STATION
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City | NACOGDOCHES
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State | TX
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Zip | 75962-0001
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Country | US
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Telephone | 936-468-4006
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BAKER PATILLO
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Credential | PHD
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Telephone | 936-468-4580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS1000X
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Taxonomy Name | Student Health Clinic/Center
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License Number |
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License Number State |
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