=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730467648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELTA STATE UNIVERSITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2011
-----------------------------------------------------
Last Update Date | 10/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1003 W SUNFLOWER RD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38733-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-846-4280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1003 W SUNFLOWER RD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38733-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 166-284-6428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT AD/HEALTH & PERFROMANCE
-----------------------------------------------------
Name | ABBY HAVARD
-----------------------------------------------------
Credential | LAT
-----------------------------------------------------
Telephone | 662-846-4280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------