=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710363098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF MARY HARDIN-BAYLOR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2015
-----------------------------------------------------
Last Update Date | 08/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 COLLEGE ST # 8011
-----------------------------------------------------
City | BELTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76513-2578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-295-5034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 COLLEGE ST # 8011
-----------------------------------------------------
City | BELTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76513-2578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-295-5034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT ATHLETIC TRAINER
-----------------------------------------------------
Name | NELLASHA DAVIS
-----------------------------------------------------
Credential | ATC, LAT
-----------------------------------------------------
Telephone | 254-295-5034
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2000022284
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------