=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528340783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISSISSIPPI COLLEGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2011
-----------------------------------------------------
Last Update Date | 09/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 CAPITOL ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39056-4026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-925-3345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 819020
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75381-9020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEAD ATHLETIC TRAINER
-----------------------------------------------------
Name | MATT VERRET
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-925-3345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1000X
-----------------------------------------------------
Taxonomy Name | Student Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------