Provider Demographics
NPI:1407967599
Name:WEST TEXAS A&M UNIVERSITY STUDENT MEDICAL SERVICES
Entity type:Organization
Organization Name:WEST TEXAS A&M UNIVERSITY STUDENT MEDICAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LUANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICKWARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:806-651-3287
Mailing Address - Street 1:WTAMU PO BOX 61401
Mailing Address - Street 2:WEST TEXAS A&M UNIVERSITY STUDENT MEDICAL SERVICES
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79016-0001
Mailing Address - Country:US
Mailing Address - Phone:806-651-3287
Mailing Address - Fax:806-651-3289
Practice Address - Street 1:2620 N RUSSEL LONG BLVD
Practice Address - Street 2:VIRGIL HENSON ACTIVITIES CENTER ROOM 104
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79016-0001
Practice Address - Country:US
Practice Address - Phone:806-651-3287
Practice Address - Fax:806-651-3289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX91914669OtherTPI