Provider Demographics
NPI:1154797371
Name:PURDUE UNIVERSITY SPORTS MEDICINE WEST LAFAYETTE
Entity type:Organization
Organization Name:PURDUE UNIVERSITY SPORTS MEDICINE WEST LAFAYETTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOC. DIRECTOR OF SPORTS MEDICINE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIPSETT
Authorized Official - Suffix:
Authorized Official - Credentials:AT, DPT
Authorized Official - Phone:765-494-3245
Mailing Address - Street 1:900 N JOHN R WOODEN DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47907-2117
Mailing Address - Country:US
Mailing Address - Phone:765-650-0727
Mailing Address - Fax:
Practice Address - Street 1:900 N JOHN R WOODEN DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2117
Practice Address - Country:US
Practice Address - Phone:765-650-0727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty