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General NPI Number Information
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NPI Number | 1154486884
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Entity Type | Organization
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Legal Business Name | CLAYTON STATE UNIVERSITY
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Dates
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Enumeration Date | 12/22/2006
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Last Update Date | 01/28/2020
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Provider Practice Location Address
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Address Line | 2000 CLAYTON STATE BOULEVARD
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City | MORROW
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State | GA
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Zip | 30260-0285
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Country | US
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Telephone | 678-466-5257
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Fax | 678-466-4699
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Provider Business Mailing Address
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Address Line | 2000 CLAYTON STATE BLVD
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City | MORROW
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State | GA
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Zip | 30260-1250
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Country | US
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Telephone | 678-466-5257
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Fax | 678-466-4699
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Authorized Official
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Title or Position | ATHLETIC DIRECTOR
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Name | RYAN ERLACHER
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Credential |
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Telephone | 678-466-4672
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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