Basic Information
| Provider Information | |||||||||
| NPI: | 1487020640 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUSHNELL UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHWEST CHRISTIAN UNIVERSITY | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SPRING VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752443995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723674845 | ||||||||
| FaxNumber: | 9723673451 | ||||||||
| Practice Location | |||||||||
| Address1: | 828 E 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974013745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416847351 | ||||||||
| FaxNumber: | 9723673451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2015 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | BASS | ||||||||
| AuthorizedOfficialFirstName: | MOUZON | ||||||||
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| AuthorizedOfficialTitleorPosition: | AGENT | ||||||||
| AuthorizedOfficialTelephone: | 9723674845 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080S0010X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
No ID Information.