Basic Information
| Provider Information | |||||||||
| NPI: | 1144649948 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINSTON-SALEM STATE UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WSSU SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SPRING VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752443995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005559073 | ||||||||
| FaxNumber: | 9723673452 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 S MLK JR DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271071370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367502597 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2014 | ||||||||
| LastUpdateDate: | 04/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | MUSHINSKI | ||||||||
| AuthorizedOfficialFirstName: | IAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEAD ATHLETIC TRAINER | ||||||||
| AuthorizedOfficialTelephone: | 3367502597 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | ATC, LAT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
No ID Information.