Provider Demographics
NPI:1427021765
Name:MISSOURI STATE UNIVERSITY ATHLETIC TRAINING SERVICESIS
Entity type:Organization
Organization Name:MISSOURI STATE UNIVERSITY ATHLETIC TRAINING SERVICESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR ATHLETIC TRAINING SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:MILTON
Authorized Official - Suffix:
Authorized Official - Credentials:AT
Authorized Official - Phone:417-836-5461
Mailing Address - Street 1:901 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-0027
Mailing Address - Country:US
Mailing Address - Phone:417-836-5461
Mailing Address - Fax:417-836-6101
Practice Address - Street 1:901 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-0027
Practice Address - Country:US
Practice Address - Phone:417-836-5461
Practice Address - Fax:417-836-6101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center