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General NPI Number Information
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NPI Number | 1982979548
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Entity Type | Organization
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Legal Business Name | GLENVILLE STATE UNIVERSITY
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Dates
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Enumeration Date | 03/15/2012
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Last Update Date | 03/15/2012
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Provider Practice Location Address
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Address Line | 200 HIGH ST
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City | GLENVILLE
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State | WV
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Zip | 26351-1200
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Country | US
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Telephone | 304-462-6223
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 819020
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City | DALLAS
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State | TX
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Zip | 75381-9020
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | HEAD ATHLETIC TRAINER
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Name | BRENT WALTERS
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Credential |
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Telephone | 304-462-6223
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS1000X
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Taxonomy Name | Student Health Clinic/Center
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License Number |
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License Number State |
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