Basic Information
| Provider Information | |||||||||
| NPI: | 1033585310 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIMESTONE COLLEGE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LIMESTONE COLLEGE SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650850 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005559073 | ||||||||
| FaxNumber: | 9723673452 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 COLLEGE DR | ||||||||
| Address2: | |||||||||
| City: | GAFFNEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293403778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644888361 | ||||||||
| FaxNumber: | 9723673451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2015 | ||||||||
| LastUpdateDate: | 08/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | BASS | ||||||||
| AuthorizedOfficialFirstName: | MOUZON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AGENT | ||||||||
| AuthorizedOfficialTelephone: | 9723674845 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.