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General NPI Number Information
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NPI Number | 1427021765
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Entity Type | Organization
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Legal Business Name | MISSOURI STATE UNIVERSITY ATHLETIC TRAINING SERVICESIS
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Dates
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Enumeration Date | 02/08/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 901 S NATIONAL AVE
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City | SPRINGFIELD
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State | MO
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Zip | 65804-0027
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Country | US
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Telephone | 417-836-5461
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Fax | 417-836-6101
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Provider Business Mailing Address
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Address Line | 901 S NATIONAL AVE
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City | SPRINGFIELD
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State | MO
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Zip | 65804-0027
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Country | US
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Telephone | 417-836-5461
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Fax | 417-836-6101
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Authorized Official
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Title or Position | DIRECTOR ATHLETIC TRAINING SERVICES
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Name | MR. IVAN EUGENE MILTON
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Credential | A.T.
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Telephone | 417-836-5461
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | MO
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